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SURGEON GENERAL'S OFFICE 

LIBRARY. 



Seciton. 




No. 113, No 

W. D.S. G.O. 






3—513 









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BY 

i|'HO*'Ka§OK OF APTATOMY IH" TIIK itmrSTEMSTirT OF ]PE:^ITSY]CnSLH'llA 

OrrE OF TIHK SIJEGEOWS TO TlHIiB PEHNSYEKMmA lIOSlPriCAlL 

ASB TO TMK PHH^ABEUPHIA MM.% HOUSE, KCo 

TIV TWO VOLUMES 



for -want of tunc)/ care 
Millioiis have died of medicable woniids. 

AKMSTltONC. 




UITI-yp^KSITr OF ]P2:RT«rSYX,'Ki^KI^\- 



PIOLAWKI J»li I A 



RiLlisKed bv I'.A^R.PaAer SC Benjanun Yaraaer. 



/ 



iiiLi^mi^]^^! 



OF 



SURGERY: 



FOR 



THE USE OF STUDENTS; 

WITH PLATES. 



JOHN SYNG DORSEY, M. D. 

PROFESSOR OF ANATOMY IN THE UNIVERSITY OF PENNSYLVANIA. 

ONE OF THE SURGEONS TO THE PENNSYLVANIA HOSPITAL. 

AND TO THE PHILADELPHIA ALMS HOUSE, &C. 

IN TWO VOLUMES. 



SECOND EDITION, WITH ADDITIONS. 



VOL. I. 



for want of timely care 

Millions have died of medicable wounds. 

Ahmstkoxo. 



PHILADELPHIA : 

I'L'BLISUED BY EDWARD & RICHARD PARKER, No. 178, AND 
BENJAMIN WARNER, No. 171, MARKET STREET. 

JOSEPH R. A. SKEHRETT, PKINTKll. 



1818. 



^B^ 



DISTRICT OF PENNSYLVANIA, to wit: 

Be it hkmembered. That on the twenty-first day of September, in the 
forty-third year of the independence of the United States of America, A. D. 
1818, Edward & Richard Parker, and Benjamin Warner, of the said district, 
have deposited in this office the title of a book, the right whereof they claim 
as proprietors, in the words following, to wit : 

"Elements of Surgery: for the use of Students; with Plates. By John Syng 
" Dorsey, M. D. Professor of Anatomy in the University of Pennsylvania, 
"one of the Surgeons to the Pennsylvania Hospital, and to the Philadel- 
•♦ phia Alms House, &c. In two volumes. Second Edition, with additions." 

In conformity to the act of the congress of the United States entitled, "An 
Act for the Encouragement of Learning, by securing the copies of Maps, Charts, 
and Books, to the authors and proprietors of such copies during the times 
therein mentioned." And also to the act, entitled, "An Act supplementary to 
an Act, entitled, "An Act for the Encouragementof Learning, by securing the 
copies of Maps, Charts, and Books, to the authors and proprietors of such 
copies during the times therein mentioned," and extending the benefits thereof 
to the arts of designing, engraving, and etching historical and other prints." 

D. CALDWELL, 

Clerk of the District of Pennsylvania. 



TO THE 



STUDENTS OF SURGERY 
THROUGHOUT THE UNITED STATES, 



THIS 



IMPERFECT ATTEMPT 



TO FACILITATE THEIR STUDIES 



IS VERY RESPECTFULLY 



INSCRIBED. 



PREFACE. 



NUMEROUS circumstances combine to render neces- 
sary an American Epitome of Practical Surgery ; those 
members of the medical profession who, by talent and 
experience, are best qualified to compose it, are fully 
occupied by other duties, and indifferent to that species 
of reputation which might accrue from such a publica- 
tion ; the labour has therefore, in the present instance ^ 
devolved upon one in many respects inadequate to the 
performance, and fully sensible of the imperfections of 
bis work. 

An American, although he must labour under many 
disadvantages in the production of an elementary trea- 
tise, is in one respect better qualified for it than an Euro- 
pean surgeon. He is, — at least he ought to be, — strictly 
impartial, and therefore adopts from all nations their 
respective improvements. Great Britain and France have 
been foremost in the cultivation of modern surgery, but 
their deficiency in philosophic courtesy and candour has 
in some instances greatly retarded its progress; to illus- 
trate this remark, it will be sufficient to state that the doc- 
trines of adhesion so ably developed in England have been 
shamefully neglected in France; and that French surgery 



If PREFACE. 

ia fractures finds no advocates in Britain. Some of tiie 
btst writings of Desanlt have never been translated into 
the English language,* and those of John Hunter are un- 
known or disregarded throughout the continent of Europe. 
TMs spirit of hostile rivalship extending from the field of 
battle to that of science, cannot fail to exert a pernicious 
influence on practical surgery, — a truth too palpable to es- 
cape the observation of any foreigner who visits an Eu- 
ropean hospital. An American in walking their wards, 
sees with surprise, in London, a fractured thigh rudely 
bound in bundles of straw, and the patient discharged 
limping with a crooked limb. In the French capital he 
witnesses an amputation, and is disgusted by the officious 
zeal with which the surgeon crams a handful of lint be- 
tween the stump and the flap which covers it, with an ex- 
press design to prevent their adhesion. It is difficult to 
reconcile these facts with one equally true, that among 
the most distinguished men who have ever adorned the 
profession of surgery, are living characters in London and 
Paris. 

As the present work is intended chiefly for the use of 
students, it is to be considered in the light of a mere in- 
troduction to other surgical writers, and that ceremony 
over, a particular acquaintance with them is earnestly re- 
commended to every one who intends to practice this im- 
portant branch of the healing art. 

» I am happy to state that Mr. Dobson is now publishing a translation of two 
very interesting volumes of Desault, for which the public will be indebted to 
the industry of Dr, E. D. Smith, of South Carolina. 



PREFACE. V 

Before closing these prefatory observations, I take the 
opportunity of disclaiming, except in a few instances, all 
pretensions to originality. I have availed myself freely 
of the writings of preceding authors, and my extracts aie 
in many instances of very unusual length ; the only apo- 
logy I shall offer for this liberty is, tliat I have conside^ 
ed it the most useful and honest method of communicating 
information. Having made this acknowledgment, 1 shall 
now state, that I believe there will be found in the follow- 
ing work many observations of practical importance, 
which are not contained in any other. These I prin- 
cipally owe to my connexion with Dr. Physick, and a 
careful attention to his practice during a period of fifteen 
years. Whether my readers will estimate them as I do, 
remains to be ascertained. 

In the succeeding pages my chief attention has been 
directed to practical precepts, and these I have endea- 
voured to deliver with clearness ; I am not without a hope 
that tliey will prove useful not only to medical students, 
but also to country practitioners, and to the younger 
surgeons in the navy and atmy. 

An apology is due for the manner in which some of the 
engravings are executed, but I trust they w ill be found 
less deficient in correctness than in elegance. 

It has been well remarked by Mr. John Bell, that 
" a book once published is like a life come to its final 
consummation ;— irrevocable ;— -needing no apologies if 



Tl PREFAUE. 

generally good, admitting none if it be not so." If any 
author, however, may justly claim the lenity of criticism, 
it is the medical practitioner, who writes and publishes 
inder circumstances every way hostile to correct compo- 
sition, and detects in his progress defects and errors, 
when the printer's stamp, like that of fate, has fixed 
theijr perpetuity. 

Philadelphia, *N*ov. ist. 1813. 



CONTENTS OF VOL. I. 



CHAPTER I. 



Page 



Grcneral remarks on accidental injuries, and their effects, 1 

Union by the first intention, . _ 2 

Ecchymosis, - _ _ _ . 3 

CHAPTER II. 

Of inflammation, - - - - - - 4 

CHAPTER III. 

Of hectic fever f - - - - - - 13 

CHAPTER IV. 

Erysipelatous inHammation, - - - - 15 

CHAPTER V. 

Of oedematous inflammation, - - - - 17 

CHAPTER VI. 

Of gangrene and mortification, - - - - 19 

CHAPTER VII. 

Ofburns, - - - - - - 30 

CHAPTER VIII. 

The effects of cold, ----- 34 

Chilblain, - - - - -35 

1 1-3 



ii CONTENTS. 

CHAPTER IX. 

Of xvoundSf . - - 

Of incised wounds. 
Of hemorrhage, 

CHAPTER X. 



I'age 

37 
lb. 
lb. 



55 



Of contused wounds. 

Lacerated wounds, - - - - ib. 

Punctured wounds, - • - - ib. 



59 



68 



CHAPTER XI. 
Of gunshot -wounds f - - - - ■ 

CHAPTER XII. 
Of poisoned woundSf - - - - 

CHAPTER XIII. 

Of particular wounds, - - - - - 72 

Wounds of the scalp, - - - - ib. 

"Wounds of the face, - - - -75 

Wounds of the eye, - - - - ib. 

Wounds of the lip, - - - - ib. 

Wounds of the tongue, - - - ib. 

Wounds of the throat, - - - - 74 

CHAPTER XIV. 

Of wounds penetrating cavities, - - - 79 

Wounds of the thorax, - - - - ib. 

Emphysema, - - - 88 

CHAPTER XV. 

Wounds penetraiing the abdomen, - - _ 91 

AVounds of the ahdominal viscera, - - 97 

CHAPTER XVI. 

Wounds of joints, ~ - ~ - -101 



GONTENTS. iji 

CHAPTER XVII. ^^^^ 

Wounds of nerves and tendons, - . . . ipg 

Wounds of veins, - . _ . 107 

CHAPTER XVIII. 

Of fractures f -- - _ _ -112 

Compound fractures, - - - 121 

CHAPTER XIX. 

Particular fractures, - - - - - 129 

Fractures of the ossa nasi, - - - ib. 

CHAPTER XX. 

Fractures of the lower jaw, - - - - 132 

CHAPTER XXI. 

Fractures of the vertebras, - - - - 135 

CHAPTER XXII. 

Fract2ires of the ribs, - - - - - 139 

CHAPTER XXIII. 

Fractures of the bones of the pelvis, - - - 141 

CHAPTER XXIV. 

Fractures of the scapula, - - - - 143 

CHAPTER XXV. 

Fractures of the clavicle, - - - - 146 

CHAPTER XXVI. 
Fractures of the OS humeri, - - - - 154 

CHAPTER XXVII. 
Fractures of the fore-arm, - . •. - 160 

CHAPTER XXVIII. 
Fractures of the wrist and hand, - - - 167 



IV CONTENTS. 



Page 



CHAPTER XXIX. 

Fractures of the thigh, - - - - 169 

CHAPTER XXX. 

Fractures of the patella, - - - - 191 

CHAPTER XXXI. 

Fractures of the leg, - - - - -195 

CHAPTER XXXII. 

Fractures of tJie bones of the foot, _ . . 20I 

CHAPTER XXXIII. 

Of wounds of bones, ----- 203 
Exloliation, ----- 207 

CHAPTER XXXIV. 

Of dislocations, - - - - -209 

CHAPTER XXXVI. 

Of particular dislocations, - - _ - 220 

Dislocation of the lower jaw, - - - ib. 

CHAPTER XXXVII. 

Dislocations of the vertebrae, - - _ - 223 

CHAPTER XXXVIII. 

Dislocations of the bones of the pelvis and thorax, - 229 

CHAPTER XXXIX. 

Dislocation of the clavicle, - - _ - 2^^! 

CHAPTER XL. 

Dislocations of the os humeri, _ _ - Q'X'^ 

CHAPTER XLI. 

Dislocations of the fore-arm, - „ _ - 241 



CONTENTS. Y 

Page 

CHAPTER XLII. 

Dislocations of the handy - - - - 246 

Luxations of the bones of the carpus and meta- 
carpus, ----- 248 
Luxations of the fingers, - - _ 249 

CHAPTER XLHL 
Dislocations of the thigh, - - - . 253 

CHAPTER XLIV. 

Dislocations of the patella, - - - - 265 

CHAPTER XLV. 

« Of internal derangement of the knee joint,'' - - 267 

CHAPTER XLVI. 

Dislocations of the bones of the leg, - - - 271 

CHAPTER XLVIL 
Of Dislocations of the foot, _ - - - 274 

CHAPTER XLVIIL 
Injuries of the head, ----- 280 

CHAPTER XLIX. 

Of concussion of tfie brain, _ - - - 282 

CHAPTER L. 

Of compression of the brain, - - - - 286 

from effused blood, - - ib. 

from depressed bone, - - 294 

Of inflammation of the brain and its membranes 

from external violence, - - - 297 

Operation of trepanning, - - - 304 

Hernia cerebri, - - - - 308 



VI CONTENTS. 

Page 

CHAPTER LI. > 

JDiseases of the eye and its appendages, - - 315 
Inflammation of the eye-lids— psoroplithalmy— 

lippitudo — hordeolum, - - 31^ — ^ 

Ectropium, - - - - - 31/ 

Entropium, - - - - 318 

Lagophthalmy, _ _ - - 321 

CHAPTER LII. 
Of ophthalmia, . _ . - - 322 

CHAPTER LIII. 
Unguis or pterygium, _ . - - 328 

CHAPTER LIV. 

Opacity of the cornea and ar I ijiciai pupil, - - 331 

Ulcers of tlie cornea, . - . 333 

CHAPTER LV. 

Fistula lachrymalis, - . - _ > 334 

CHAPTER LVI. 

Of cataract, - - - - - -340 

CHAPTER LVII. 

()f extraction, - - . - - 351 

CHAPTER LVIII. 

Of couching, ----- 358 

CHAPTER LIX. 

Of congenital cataract, - . _ - 365 

Hypopion, - - - , - 371 

Staphyloma, - - . - ib. 

CHAPTER LX. 

Extirpation of the eye, - . . - 388 

Tapping the eye, - - . - 389 



CONTENTS. Vll 

Page 

CHAPTER LXl. 
Of polypus, ------ 392 

CHAPTER LXn. 
Of ranulUf ------ S96 

CHAPTER LXUI. 
Of salivary jistul(B, ----- 598 

CHAPTER LXIV. 

OJ abscess of the antrum maxillare, - - - 400 

CHAPTER LXV. 

Diseases of the tongue, - - - - 402 

CHAPTER LXVI. 

Diseases of the uvula and tonsils, _ - - 404 

CHAPTER LXVII. 

Of foreign bodies in the oesophagus, - - - 406 

CHAPTER LXVni. 

Of strictures of the oesophagus, - - - 410 

CHAPTER LXIX. 

Of obstructions in the glottis and trachea, - - 412 

Operation of laryngotomy, - - - 417 

CHAPTER LXX. 

Accidents and diseases of the ear, - - - 419 



ELEMENTS 



OF 



SURGERY 



CHAPTER I. 



General Remarks on Accidental Injuries, and th&xr 

Effects, 

XT is the business of the surgeon to provide remedies 
for the various accidents to which the human body is 
liable ; the treatment of many of its diseases is also com- 
mitted to his care. As accidental injuries are more sim- 
ple and intelligible than diseases, it will be proper to 
commence an elementary work on surgery with some 
general explanations of their nature and effects. 

The most simple accident, which can possibly occur, 
appears to be that degree of concussion, " in which the 
only effect produced, is a debility of the actions or func- 
tions of a whole or part, similar to that occasioned by a 
bruise, in which the continuity of the substance is not 
interrupted; in such a state, the parts have little to do, 
but to expand and reinstate themselves in their natural 
position, actions, and feelings ; and this is what happens 
in the concussion of the brain." 

VOL. I. 3 



2 ELEMENTS OF SITRGERY. 

The rupture of a small blood-vessel is perhaps the 
next in order of simplicity; when the continuity of the 
part is broken, extravasation takes place, and the blood 
is effused into the common cellular membrane, into the 
interstices of some part, or into a circumscribed cavity.* 
But should the vessel be either very large, or essential 
to life, such as the femoral, bracheal, or coronary arteries ; 
or should the rupture take place in a vital part, as the 
brain, in such cases the injury may kill from the extra- 
vasation alone, however inconsiderable may be the ori- 
ginal mischief. 

Another species of injury is that in which the ruptured 
parts have an external opening, constituting a wound. 
The nature and circumstances of wounds will be consi- 
dered in another place. The oi)eration of restoration in 
this case consists, first in the coagulation of the extrava- 
sated blood between the ruptured parts, laying as it were 
the foundation of union, next in closing the ruptured ves- 
sel, or in promoting its inosculation, and afterwards in 
bringing about an absorption of the superfluous coagulat- 
ed blood. Whether in these cases a new portion of ves- 
sel is formed, or whether the original vessel re-unites 
without the intervention of a new cylinder is not easily 
determined. 

This mode of restoration is called union by the first 
intention; it is evident that it can only happen in cases 
where the extent of the divided parts is small, and their 
surfaces nearly in contact. In this case, the blood effused 
by the accident is the bond of union, and it evidently be- 
comes living flesh. 

When the quantity of blood poured out is very great, 
even in parts not essential to life, considerable inconve- 

* Fractures of tendons, simple fractures of bones, and many other injuries, 
in which there is no external communication, are considered by Mr. Hunter as 
similar in nature to this accident. 



ELEMENTS OF SURGERY. g 

nience results from the inability of the absorbents to re- 
move it. An effusion of blood under the skin, or in the 
interstices of any part of the body, is called Ecchymosis, 
and in some cases calls for surgical treatment. As the 
subject will not be resumed, I shall state here the proper 
remedies. They are rest, moderate pressure, and cold 
aj)j)lications ; as cold lead water , cold vinegar and water y 
^c. by the use of these means the blood will generally 
be absorbed, during which process the skin, which had 
been of a dark purple colour, becomes blue, green, yel- 
low, and assumes a variety of hues. The blood most fre- 
quently in Ecchymosis coagulates, but it sometimes re- 
mains fluid; and in this latter case, is apt to inflame and 
suppurate; to prevent which, a puncture should be made 
with a lancet into the cavity containing the blood, which 
must be emptied by gentle pressure. After which care 
should be taken to approximate the sides of the puncture, 
that they may speedily unite. If, notwithstanding these 
remedies, the parts inflame and suppurate, the case is to be 
treated like any other abscess. If, from this, or any other 
cause, union by the first intention is prevented, another 
mode of restoration is effected by means of inflammationi 



4i ELEMENTS OF SURGERY. 

CHAPTER II. 

Of Inflammation. 

A COMPLETE acquaintance with this subject is essential 
to every practitioner of surgery. In the following remarks 
I shall endeavour to describe its phenomena without at- 
tempting to investigate the theories which have been 
formed to explain them. 

Inflammation generally commences with an increased 
sensibility of the part; pain is soon perceived, attended 
with heat, redness, and tumefaction; the pulsation of the 
arteries in the inflamed parts occasions a throbbing, which 
in some situations is very distressing to the patient, as 
when the inflammation is seated in one of the fingers. 
The pain is attributed by Mr. Hunter to a spasm of the 
vessel, analogous to cramp, tetanus, &c. The tumefaction, 
is owing to the enlarged diameters of the vessels, and to 
the effusion of serum and coagulating lymph in their in- 
terstices. The heat of an inflamed part never transcends 
the heat of the animal at the source of circulation, though 
the sensation would lead to a contrary belief.* 

Inflammation is divided by surgeons into healthy and 
diseased. By healthy is understood, that which has for 
its object the restoration of injured parts; by diseased, 
that in which some morbid peculiarity is superadded to 
the simple act of inflammation, as in erysipelas, carbun- 
cle, &c. 

The remote causes of healthy or phlegmonous inflam- 
mation, are various irritations of a mechanical or chemi- 
cal nature; wounds, bruises, acrid substances, &c. Some- 

» The heat and redness are probably owing to the increased rapidity of cir- 
culation; but in what particular manner is n*t clearly understood. 



ELEMENTS OF SURGERY. g 

times inflammation appears to arise as a consequence of 
febrile diseases, forming what has been called, critical 
abscess ; and in other instances no evident cause can be 
assigned, these cases are very improperly considered 
spontaneous, as they have certainly a remote cause, al- 
though it be not obvious. 

1l\vq -proximate cause of inflammation has been a source 
of much theoretical discussion. Mr. Hunter considered it 
as an increased action of the blood vessels, and this at 
the present time is a generally received opinion.* 

A variety in the exciting cause seems to have no effect 
in varying the nature of healthy inflammation; though 
different circumstances of the constitution or part, afl'ect 
its progress very materially. Strength of constitution; a 
vigorous circulation of the blood ; and vicinity to the 
source of circulation, are circumstances highly favoura- 
ble to its progress, and under opposite circumstances, 
inflammation frequently terminates unfavourably. The 
legs, when inflamed, heal much less readily than the su- 
perior parts of the body. The colour also of an inflamed 
part, depends on similar circumstances. An inflamed leg 

• On this subject see Hunter on the blood, &c. and also Dr. Wilson's Essays 
onFebrile Diseases, in which thedoclrinesofMr. Hunter are ingeniously.though 
I think, unsuccessfully opposed. Mr. John Pearson, with his usual accuracy, 
remarks, « hy proximate cause is to be understood a real physical cause, so inse- 
parably connected with the disease, that the presence of the one implies the 
agency of the other: upon the existence and duration of the proximate cause, 
depends the existence and duration of the disease ; and if the former be changed, 
there is a correspondent change inthe latter." This is precisely what Dr. Rush 
means when he declares, in the language of Gaubius, the proximate cause of a 
disease to be « ipse morbus." Thajimere increased action is not the proximate 
cause of inflammation, can easily be proved. Now since the action of inflamma- 
tion is altered from healthy action, and since we cannot tell in what th.s altera- 
tion consists, it appears to me best to confess, that in the present state of our 
knowledge, the proximate cause of inflammation is not distinctly known. The 
degree of action in inflammation varies very greatly ; sometimes it is feeble, and 
sometimes violent. The nature of the altered action of vessels in inflammalion, 
is not more likely to be discovered, than the nature of those actions wluch m the 
liver form bile, in the kidneys urine, &c. The mere alternate contraction and 
dilatation of blood-vessels offer no explanation on any of these subjects. 



6 ELKMENTS OF SURGERY. 

is darker than an inflamed arm. When seated in \ery 
vascular parts, as skin, cellular membrane, muscle, — it is 
more rapid in its progress and more favourable in its ter- 
mination, than in those which are less so ; as bone, ten- 
don, or ligament. As an exception to this remark, how- 
ever, we must state, that when inflammation attacks vital 
parts, notwithstanding their great vascularity, it does not 
proceed so favourably as in those of a similar structure, 
which are less essential to life. 

Healthy inflammation is always greatest at the part 
nearest the external surface of the body. When it attacks 
the socket of a tooth, it affects the external part next the 
eheek; when it occurs in the vicinity of the rectum, it 
affects the skin and cellular texture, leaving the intestine 
sound. 

The effects of local inflammations upon the constitu- 
tion, depend much on their extent and situation. Where 
they are small, very little inconvenience results ; where 
they are extensive, or seated in vital parts, greater irrita- 
tion, and considerable fever, are the consequences. In- 
flammation occurring under a tendinous fascia, produces 
more effect on the constitution than the same decree of 
inflammatory action in other parts. The fever produced 
is called symptomatic, and is generally attended with a 
quick tense, full pulse, and sizy blood. 

Healthy inflammation is always attended by one or 
more of the following effects — an adhesion of the inflam- 
ed parts, one to another ; the formation of pus, and the 
removal of portions of the body by the absorbent vessels. 
The uniform occurrence of these effects induced Mr. 
John Hunter to describe inflammation in three different 
stages ; the adhesive, su])puratwe, and ulceratwe. The 
various parts of the body differ in their susceptibility of 
adhesion, suppuration, and ulceration. The cellular 
membrane ; the circumscribed cavities; as the abdomen, 



ELEMENTS OE SURGERY. 



7 



thorax, tunica vaginalis, very readily form adhesions : — 
Mucous membranes, on the contrary, as the nose, mouth, 
alimentary canal, the air cells of the lungs, the trachea, 
&c. very seldom adhere, but readily suppurate. It is 
generally found that deep-seated parts suppurate less 
readily than superficial: hence, if a musket-ball be lodg- 
ed at any considerable depth in the body, it excites adhe- 
sive inflammation, and a cyst forms round it; but if it 
be lodged nearer the surface, it produces suppuration, an 
abscess forms, and it is discharged. 

The symptoms of inflammation which have been des- 
cribed, exist very evidently in the adhesive stage, but 
when suppuration is about to commence, they are greatly 
aggravated ; the pain and throbbing become more violent^ 
the heat is augmented, the swelling is more prominent, 
the colour more intense, and approaching to a pale scar- 
let. Shivering fits come on, the swelling grows softer, 
and matter is formed, fluctuation may be perceived by ex- 
amination with the fingers : an immediate abatement of 
the symptoms now takes place. 

If the inflammation be seated in the cellular membrane, 
the process of ulceration now commences, and the absor- 
bent vessels remove the solid parts of the body to make 
room for the lodgment of the pus secreted, and also to pre- 
pare a way for its escape. In this manner an Abscess is 
formed, which may be defined a circumscribed cavity, 
containing pus. In a common phlegmonous abscess, we 
have a good example of the three eff'ects of inflammation 
which have been briefly noticed. At its nifirgin, where 
the inflammation is least violent, the inflamed vessels se- 
crete coagulating lymph, which agglutinates and firmly 
unites the cells of the cellular texture, circumscribing the 
cavity, and preventing tlie escape of the matter into the 
surrounding parts. Towards the centre of the abscess 
inflammation has transcended the adhesive stage, and the 



g ELEMENTS OF SURGERY. 

blood-vessels have relieved themselves by a secretion qt 
pus. This process immediately excites the action of the 
absorbing vessels, which remove the solid matter to form 
a cavity to contain this pus. 

The natural cure of an abscess consists in the absorp- 
tion of all the solid matter intervening between the pug 
and the cuticle, by the rupture or bursting of which, an 
outlet is made for the evacuation of the cavity, after which 
small projecting vascular spots appear, in every part of 
it, called granulations, which are formed of the coagu- 
lating lymph of the blood, which fill up gradually the 
cavity, and unite one with another, forming solid flesh — 
a formation of cuticle takes place on the surface, and thus 
the parts are restored nearly to their pristine state.* 

The terminations of inflammation are various. In some 
instances it terminates by what is called resolution. In 
this case all the symptoms gradually subside, and the 
parts are restored to their natural colour and appearance. 

The secretion of pus, already noticed, is to be consi- 
dered one of the terminations of inflammation. A secre- 
tion of serum frequently puts a stop to the inflammatory 
process. The inflammation from cantharides terminates in 
this way. Instances of tliis we see also in inflammation 
in the brain, ending in hydrocephalus. In the tliorax, 
terminating in hydrothorax, &c. 

Hemorrhagij has occurred in some cases, and put an 
immediate stop to inflammation. 

Hard tumours occasionally form by the secretion of 
coagulating lymph in the interstices of parts, and this 
has been called a termination of inflammation in scirrhus. 

In other instances the violence of action or the kind of 
action exhausts the vital powers of the inflamed part and 
the inflammation terminates in mortification. 

* For a particular account of the process by which cavities are filled up I 
refeT to Mr. Huater, aud u paper by Mr. James Moore. 



ELEMENTS OF SURGERY. n 

TREATMENT OF INFLAMMATION. 

In the treatment of inflammation the first object is, to 
remove if possible the remote causes, if they continue to 
act. The next is to lessen the inflammatory action. The 
remedies to eflPect this latter object are general, or consti- 
tutional, and local. Those which act on the constitu- 
tion are, 

1st. Blood-letting. This is a powerful remedy in 
the treatment of inflammation. The quantity of bbod to 
be drawn, and the frequency of its repetition, can only 
be estimated by the violence of the inflammatory symp- 
toms. Whenever parts essential to life are inflamed, as 
the brain, or the contents of the thorax, or abdomen, 
repeated and copious bleedings become necessary. 

2d. Low Diet — Tends not only to diminish the full- 
ness of the vessels, but also to lessen irritation, and 
should be strictly enjoined. 

3d. Purging is often necessary in the treatment of 
inflammation. But in many cases it is inconvenient on 
account of the necessity which it occasions for moving the 
patient, as in cases of fractured bones. Blood-letting must 
therefore be substituted. 

4th. Certain Neutral Salts — Sulphate of Soda, 
Sulphate of Magnesia, Nitrate of Potash, &c. are use- 
ful, by promoting the secretions, and are generally com- 
bined with preparations of antimony ; in which case they 
occasion nausea, and diminsh the action of the blood- 
vessels. 

5th. Rest is essential, for motion occasions irritation 
and many inflammatory aifections are found difficult of 
cure, because the inflamed parts cannot be kept at rest; 
fistula in ano affords an illustration of this remark. 

VOL. t. 3 



iO ELEMENTS OF SURGERY. 

6th. Position. The posture of the body should be 
Isuch as to favour the return of blood from the inflamed 
part. In many local inflammations, posture is of extreme 
importance. The elevation of the feet in cases of inflam- 
mation on the lower extremities, is found highly useful. 
It forms indeed one of the methods of depleting by emp- 
tying the blood vessels of the affected part. 

7th. Opium may be given to relieve pain in some cases. 

The local remedies, are, 1st. Bleeding from the inflam- 
ed part by cupping, leeches, and scarifications. Local 
blood-letting is most effectual after general bleeding has 
been premised. 

2d. Cold Applications are sometimes of service, 
but they should only be carried so far as to be pleasant 
to the feelings of the patient. A very common application 
which is intended to reduce the temperature of inflamed 
parts, is a solution of sugar of lead, with or without the 
addition of vinegar. 9j of acetate of lead, to §iv of water, 
answers the purpose as well as any other preparation. 
It is to be applied on linen rags ; and, as it soon acquires 
the temperature of the part, these rags should be often 
changed. 

3d. Blisters are, in certain cases, of great use in dimi- 
nishing inflammation. They must be applied directly 
over the inflamed part; and in many cases, produce a 
speedy cure. 

All these remedies tend, by diminishing the violence of 
inflammation in its adjiesive stage, to prevent suppura- 
tion, which is generally to be attempted : but cases oc- 
cur in which this event is desirable, and others in which 
it is inevitable. The best application in such cases is 
a soft poultice of bread and milk, with the addition of a 
little sweet oil, or fresh lard; or ground linseed and 
water. 



ELEMENTS OF SURGERY. |^ 

, When suppuration has taken place, and a fluctuation 
of matter can be perceived, if it be not soon evacuated 
by absorption, it becomes necessary to expedite the cure 
by an artificial opening. 

Abscesses should be opened early, when situated near 
the larger cavities of the body, as the thofax or abdo- 
men, instances having occurred in whicli they have dis- 
charged their contents into these cavities, occasioning 
fatal consequences. In paronychia, or other very pain- 
ful collections of matter, especially where the pus is con- 
fined under a tendinous fascia, an early opening should be 
made ; — when situated near large joints ; — when they 
impede respiration or deglutition; — when tliey occasion 
nervous fever, or other constitutional aflFections, they 
should be opened early. The best application after the 
cavity of an abscess is evacuated is a soft linseed or bread 
and milk poultice.* 

There are two ways of opening abscesses ; by incision 
or puncture, and caustic. The lancet is to be preferred 
whenever we can choose ; if the patient, however, from 
great fear of a cutting instrument obstinately refuses to 
submit, caustic may be substituted — a piece of caustic 
vegetable alkali rubbed over the part eight or ten min- 
utes, will occasion a slough, and give vent to the pus. 

The properties of pus have been well described by 
Mr. Home. It is a light straw-coloured fluid of the con- 
sistence of cream, composed of globules swimming in a 
fluid, which fluid is coagulable by muriate of ammonia — 
a property which distinguishes pus from all other animal 
fluids. Healthy pus is perfectly bland, free from all acri- 

* A very ready mode of preparing' the linseed poultice, is to mix the linseed 
meal with warm water until it acquires- a proper consistence. If the linseed 
meal be not at hand, it is easily prepared by passing common flax seed through 
a eoffee-mill. 



^2 ELEMENTS OF SURGERY. 

mony. It is heavier than water, and sinks in it without 
mixing. Pure pus does not readily putrefy; but when 
mixed with blood or extraneous matter it ferments and 
becomes putrid, acquiring a fetid smell, and is now acrid 
and irritating. It is evidently a secreted fluid poured out 
by the inflamed vessels which assume the nature of a 
gland. 



ELEMENTS OF SURGERY. jo 

CHAPTER III. 

Of Hectic Fever. 

Fever results from every extensive local inflamnia- 
tion. This fever is called symptomatic, but if the local 
disease continue for a great length of time, and until the 
system is weakened, febrile symptoms of a very differ- 
ent character ensue and constitute what is called hectic 
fever. 

The symptoms of hectic, are, great weakness ; a fre- 
quent small pulse, a moist skin, copious flow of urine, 
moist tongue, loss of appetite, nausea, occasional vomit- 
ing, night sweats, diarrhoea, frequent chills succeeded 
by flushes of heat; watchfulness to a distressing degree, 
and flatulency together with the several symptoms of in- 
digestion. 

Hectic fever has been ascribed by Dr. Cullen and many 
others to the absorption of pus. This opinion is however 
without foundation, and many facts concur to prove that 
copious absorption of matter may take place without hec- 
tic fever, and many cases of hectic fever occur unattended 
by an absorption of pus. Of the former we have exam- 
ples in the absorption of matter from buboes and other 
abscesses, which are not followed by symptoms of hectic, 
and of tlie latter we have instances in those cases of scro- 
fulous joints in which hectic fever precedes suppuration, 
an occurrence by no means unusual. 

The cure of hectic fever will in vain be attempted, 
whilst the local disease which gives rise to it continues. 
If the local inflammation be absolutely incurable, and in 
such a situation as to admit removal by a surgical opera- 
tion, this ought always to be done. The effects of re- 



i-t ELEMENTS OP SURGERY. 

moving even a small local irritation, are in some instances 
truly astonishing. Patients apparently on the brink of 
the grave, become convalescent in a few hours. 

If however the part can neither be cured nor removed, 
the strength of the patient must be supported by an in- 
vigorating diet and tonic remedies. The Peruvian bark 
and opium are here valuable medicines, and must be ad- 
ministered according to the exigency of the case. 



ELEMENTS OF SURGERY. 4^ 

CHAPTER IV. 

Erysipelatous Inflammation. 

This has been considered a disease of the cutis vera; 
it diiFers from healthy inflammation in many circumstan- 
ces. It commences at a particular spot and very rapidly 
extends itself, sometimes over a large portion of the body. 
In some cases it is preceded by a chill and general fever, 
in other cases the local affection is first observed. 

The colour of the skin when affected with erysipelas 
is a bright scarlet. There is less tumefaction than in 
phlegmon, but yet some elevation of the inflamed part, 
and a decided line of distinction where it terminates. 
Pressure on the skin causes the redness to disappear, 
but on removing it, the colour quickly returns. The pain 
differs from that of phlegm.onous inflammation ; it is of a 
burning kind and attended in many instances with intol- 
erable itching, especially when seated on the nates and 
perineum. When it occurs in the face, it is attended with 
greater tumefaction than in any other part, and is more 
dangerous. The cellular membrane around the eyes are 
much swollen and appear as if distended with a fluid 
having a semi-pellucid appearance. In some cases it is 
attended with vesications, which contain a fluid some- 
what acrid, when these burst, scabs are formed and a 
sore beneath them. 

In erysipelas there is never a secretion of coagulating 
lymph. It either terminates in resolution, or in a kind 
of suppuration, or else in gangrene. When suppuration 
takes place, as there is no secretion of coagulating lymph 
to circumscribe the abscess, the pus travels through the 
cells of the cellular membrane, occasioning violent in- 



16 ELEMENTS OF SURGERY. 

flammatioii and gangrene, the parts slough out, and have 
a very strong resemblance to wet tow. I have seen death 
occasioned in sucli a case by the very extensive diffusion 
of the matter through the cellular texture producing mor- 
tification wherever it went. 

Where the affection is limited in extent and moderate 
in degree, it generally gets well in a week or ten days, 
the skin casting off its cuticle in small flakes like bran. 

The constitutional symptoms are in many cases very 
severe, great debility, head-ache, nausea, vomiting fol- 
lowed by violent fever and dejirium. 

The remote causes of erysipelas cannot be distinguish- 
ed from those of common inflammation. The state of con- 
stitution, appears to influence them in producing phleg- 
mon in some cases and erysipelas in others. 

TREATMENT. 

The remedies are the same as for common inflamma- 
tion. Bleeding is generally indicated ; purging — low 
diet — neutral salts and antimonials, are to be adminis- 
tered according to the exigency of the case. In London, 
bark and tonics are very frequently exhibited with ad- 
vantage, but an opposite plan of treatment is required in 
America. As a local application, rye meal or wheat flour 
is found pleasant and useful; poultices and all unctuous 
substances do mischief. Cold lotions are sometimes used 
with advantage ; a solution of acetate of lead is the best. 
Blisters are a remedy of great efficacy; in some instances 
they occasion an immediate cessation of the disease. The 
late Dr. Pfeiffer, of this city was in the habit of employ- 
ing them for many years with advantage in cases of ery- 
sipelas. When suppuration takes place large opening's 
must be made for the evacuation of the pus and sloughs. 



ELEMENTS OF SURGERY, 4y 

CHAPTER V. 

Of (Edematous Inflammation. 

The following remarks of Mr. Hunter contain a very 
accurate account of tliis affection. " What I would call 
the cedematous inflammation is, when the extravasated 
fluid is water. It lias very much the appearance of the 
adhesive, and comes probably the nearest to it of any, be- 
ing of a scarlet colour, but much more diffused. The fluid 
extravasated, being principally the serum, renders the 
swelling more diffused than even the inflammation itself. 
It is very painful, or rather sore, but there is not so much 
of the throbbing sensation as in the adhesive inflamma- 
tion ; it appears to be only the surface, but most probably 
goes much deeper: for in such cases the extravasated 
fluid is in too large quantity to be furnished by the cells 
of the cutis alone, but in this we have not the same guide 
as in the adhesive, namely, tlie swelling and inflamma- 
tion corresponding with each other. 

'' The difference between this inflammation and the ad- 
hesive arises, I conceive, from the principle of inflamma- 
tion acting upon a dropsical disposition, which is always 
attended with weakness, whereas a greater degree of 
strength would have produced the adhesive inflamma- 
tion under the same cause or irritation, and w^hat makes 
me conceive this is, that in many cases of anasarcous legs 
we have exactly this inflammation, come on from disten- 
tion, which adds to the extravasation of the serum, as 
well as in most cases of scarifications of (edematous parts 
to evacuate the water. When inflammation takes place it 
is much more lasting than the adhesive, and, I believe, 
seldom or ever produces suppuration ; but if it should 

VOL. I. 4!' 



^8 ELEMENTS OP SURGEUY. 

run into this stage it is more general, and the whole cel- 
lular membrane, in the interstices of parts, is apt to mor- 
tify and slough, producing very extensive abscesses, 
which are not circumscribed." 

The remedies before the secretion of water takes place, 
are the same as for common inflammation. We shall add 
a few words on this subject in the chapter on ulcers. 



ELEMENTS OF SURGERY. ^9 

CHAPTER VI. 

Of Gangrene and Mortification. 

Mortification is the entire death of a part of the 
body, gangrene is that state or condition which immedi- 
ately precedes it. It is gangrenous so long as it retains 
sensibility, motion, and warmth, when these cease and it 
acquires a livid, brown, or black colour, it is mortified, or 
in a state of sphacelus. 

Mortification is of two kinds : the one is not preceded 
by inflammation, the other is. 

I. Mortification, not preceded by inflammation, may 
be occasioned by a variety of circumstances. Interrup- 
tions to the circulation of the blood, as the application of 
a ligature to the arterial trunk supplying the part, or pres- 
sure on the large veins by which the return of blood is 
prevented, as in strangulated hernia. Continued pres- 
sure on a part of the body, occasions mortification : this 
is seen in the hips and backs of patients who have been 
long confined to one posture in bed. Disorganization by 
external violence, intense heat or cold, also produce mor- 
tification which i-s not preceded by inflammation. When 
mortification from any of these causes commences, the 
parts become livid, cold, purple, black, lose all sensibi- 
lity, become covered with vesications, containing a bloody 
dark serum, and at length putrefy, and emit a fcetid 
smell. ^ These cases admit of no remedy. A soft bread 
and milk poultice is to be applied to prevent the dead 
parts from becoming hard and dry, and thereby adding 
to the irritation. If the part mortified be very extensive, 

•The process of "sloughing-," in surgical language, signifies the separation 
of dead and living parts. 



20 ELFMENTS OF SURGERY. 

the constitution sinks, and death takes place. The use of 
tonics and stimulant medicines, are necessary in these 
cases. Peruvian bark, elixir of vitriol, and opium, are 
among the most useful. 

When a part has been exposed to intense cold, the 
greatest care should be taken to raise its temperature 
gradually, as it is found invariably to mortify when heat 
is suddenly applied. It should first be placed in ice or 
snow, afterwards in cold water, and very gradually 
warmed. 

In some rare instances, mortification comes on without 
any evident cause, except extreme debility. I have 
known an instance of this after a severe attack of yellow 
fever. This is, probably, not preceded by inflammation. 

II. Mortification in many instances is preceded by in- 
flammation. 1. It may arise from the violence of the in- 
flammatory action exhausting the vital powers of the 
part; or, 2dly, from some peculiarity in the nature of the 
inflammation. 

1. "Inflammation is an increased action of that power 
which a part naturally possesses, and in healthy inflam- 
mations at least, it is probably attended with an increase 
of power. In cases however which are to terminate in 
mortification, there is no increase of power, but on the 
contrary a diminution of it. This when joined to an in- 
creased action, becomes a cause of mortification, by de- 
stroying the balance which ought to subsist between the 
power and action of every part.'' (Hunter.) 

When inflammation has, either not been properly 
treated, or has resisted the remedies usually successful, 
and is about to terminate in mortification, the pain and 
fever suddenly ceases, the heat is diminished, the red 
colour is changed to a dark purple, and the swelling 
which was tense and hard, becomes softer. The cuticle 
is elevated in various places and vesications form, filled 



ELEMENTS OF SURGERY. ^i 

with a darkish and sometimes a transparent fluid. This 
gangrenous condition rapidly progresses to a complete 
mortification, attended with putrefaction. 

The constitutional remedies for it are all such as by 
lessening inflammatory action, have a tendency to pro- 
duce resolution or suppuration. These have been al- 
ready mentioned, in the chapter on inflammation. Where- 
ever tiie violence of the symptoms lead to an apprehen- 
sion of gangrene, the evacuations by bleeding, purging, 
&c. are to be increased, and carried as far as the state of 
the system will warrant. 

The indiscriminate use of evacuating remedies, is how- 
ever by no means proper. The sudden diminution of 
strength which frequently precedes mortification, de- 
mands a very opposite mode of treatment, and here tonic 
remedies are strongly indicated. Wherever the inflam- 
matory action suddenly subsides, and with it the symp- 
tomatic fever, and a great diminution of vigour is per- 
ceived in the patient's constitution, the use of tonics and a 
generous diet, with fermented liquors, especially wine, 
are to be directed. These remedies have no eflect cer- 
tainly on parts already mortified, but they fortify those 
which are not, and thereby prevent the progress of the 
gangrene. 

The Peruvian bark has long been celebrated for its 
virtues in this particular case. It is a valuable tonic, 
but has probably no specific virtues, and has done great 
mischief when administered during an inflammatory state 
of the system. The encomiums lavished on it at the be- 
ginning of the last century, appear to have been extrava- 
gant, and surgeons no longer recommend its indiscrimi- 
nate exhibition in cases of gangrene. When the stomach 
rejects it in substance, it may be administered in decoc- 
tion, but it often produces so much nausea, that its exhi- 
bition is necessarily precluded. 



g^ ELEMENTS OF SURGERY. 

The local remedies which have been used in cases of 
mortification, are various. In the first place, if there 
exist any local irritation which has a tendency to keep 
up the inflammatory action, and thus extend the mischief, 
these are to be removed. The application of cataplasms 
and poultices can have no effect on the mortified parts 
except by keeping them moist, or correcting the fcetor 
which exhales, but these are important objects and should 
not be neglected. A poultice of bread and milk mixed 
with laudanum; of linseed, or of scraped carrots well 
boiled in milk answers in general every purpose, and if 
renewed once in three or four hours keeps the parts suf- 
ficiently clean, but in warm weather when the smell is 
very foetid, the addition of finely powdered charcoal to 
the poultice of linseed, gij. to the pound, has some effect 
in rendering it more tolerable. A poultice consisting of 
oatmeal and beer, stirred together until they have a pro- 
per consistence, is much used by surgeons with a similar 
intention. The fermenting cataplasm, with or without 
the addition of charcoal, is also a useful application. It 
is made in several ways ; the easiest and therefore the 
best, is by mixing equal parts of yeast, flour and honey 
— if requisite, powdered charcoal may be added. 

Certain stimulating applications have been much used j 
the various balsams, resins, aromatics, alkohol, &c. 
They are in general laid aside. The temperature of the 
local applications should be attended to ; if they be ap- 
plied too hot, they increase inflammation, and if too cold, 
they weaken the parts. The temperature should be near- 
ly that of the part to which they are applied, and they 
must always be light, so as not to offend by pressure. 

Scarifications, if ever, are very rarely necessary. 
There can be however no doubt of the propriety of mak- 
ing punctures through mortified parts whenever there is 
confined acrid matter beneath them, irritating the living 



ELEMENTS OF SURGERY. go 

parts; they should never extend into sound flesh. In 
cases of gangrene from erysipelas, this practice is particu- 
larly necessary. Wherever extensive sloughing of the 
cellular membrane from any other cause, as extravasated 
urine, &c. takes place, they are equally proper, but they 
should never be used with a view to expose the sound 
parts, in order to apply local remedies to these. When 
performed with this view, they occasion great pain and 
inflammation, and must therefore add to the danger and 
spread the mortification. 

The knife should not in general be used with a view 
to separate the dead from the living parts ; this separa- 
tion will be readily effected by a natural process institut- 
ed by the absorbent vessels, and to them it should be com- 
mitted. 

When gangrene is situated in one of the extremities, 
it has been the practice of some surgeons to amputate the 
member. The dangers attending this practice, and the 
fatal result of a great number of cases, have induced 
modern surgeons to lay it aside. 

When the limb is completely mortified and putrid, and 
the absorbents have begun to separate the dead from the 
living parts, portions of the putrid flesh may be cut off 
to diminish the smell, but this should be done with great 
care, so as in no instance to injure the living parts. After 
the whole of the soft parts are separated by the absor- 
bents, the bones may be sawed through ; but it commonly 
happens that the bone has mortified higher tlian the flesh, 
and therefore, the same process of separation by the ab- 
sorbents must be waited for, so that the only advantage 
arising from the operation is a removal of the inconveni- 
ence of a putrid and offensive mass, the cure not being at 
all expedited by the operation. 

I shall conclude this account of the local treatment 
of mortification consequent to inflammation, by recom- 



24 ELEMENTS OF SURGERY. 

mending in every instance the application of a blister, 
large enough to cover all the sound parts in contact with 
the diseased. This remedy was introduced into prac 
tice by Dr. Physick, who was led to apply it from the 
success of blisters in cases of erysipelas. He first em- 
ployed it in January 1803, and from that time until the 
present, has had the greatest reason to be pleased with 
its effects. A great number of cases have occurred in 
various parts of the United States, in which an immedi- 
ate cessation of the progress of the gangrene has been the 
result of its application. I have witnessed its effects in 
a variety of instances, and have no hesitation in recom- 
mending it, in preference to all other local remedies. 
After the first dressing of the blister, it will generally be 
found that the mortification has ceased to progress, and in a 
very short time the separation of the sloughs commences. 

S. Mortification it was observed appears in some cases 
to arise from something peculiar in the nature of the in- 
flammation which precedes it, independently of its appa- 
rent violence. The pustule of small-pox and carbuncle 
are specimens of this. 

The inflammation of the small-pox pustule terminates 
by occasioning the death of that portion of cutis vera ia 
which the inflammation was situated. 

Carbuncle. Tliis is a tumour beginnins; on different 
parts of the body, most frequently on the back ; the pain 
attending it is very great, and of a burning kind ; the skin 
itches, and under it is found a very hard circumscribed 
tumour, which becomes of a dark red colour. A kind of 
imperfect suppuration takes place under the skin, attend- 
ed with gangrene of the cellular membrane, and skin; 
sloughs form, and several openings are thus made into 
the cavity of the tumour, which discharges a fetid pus. 

The size of these tumours varies greatly, in some in- 
stances, they are small, in others many inches in diame- 



ELEMENTS OF SURGERY. gg 

ter — I have seen them extending quite across the back. 
In general they occur in advanced life, and in those who 
have lived well. When they are very large they often 
terminate fatally ; in those instances where several occur 
at once, they are also fatal. Carbuncle occasionally forms 
on the head, or high on the neck, and these cases gene- 
rally terminate unfavourably when they are large. In 
sound constitutions and in patients not very far advanced 
in life, a cure may commonly be expected. 

The cure depends greatly upon the state of the consti- 
tution, and this must influence our prescriptions: in ge- 
neral great debility attends, and demands a cordial in- 
vigorating diet. Opium must be given to relieve pain, and 
the bark and elixir of vitriol may often be used with ad- 
vantage. 

As a local remedy, the application of a blister is to b« 
preferred to all others ; I have known it produce imme- 
diate relief of the distressing burning sensation which 
invariably attends this complaint, and occasion a speedy 
separation of the sloughs. As soon as matter fluctuates 
under the skin, an incision must be made to discharge 
it, and a free passage is to be kept open for the evacua- 
tion of pus and sloughs. A plaster of common basilicon 
after the blister has been cut is to be applied, and if poul- 
tices are used, they should be very light and frequently 
changed. 

Besides the cases of mortification which have been de- 
scribed, there is a species of mortification which takes 
place in the toes and feet of old persons, w hether or not 
it is preceded by inflammation is undetermined; Mr. 
Hunter thinks it is. 

The following account of this singular ajBTection is 
taken from the writings of Mr. Pott. 

^^ It is very unlike to the mortification from inflamma- 
tion, to that from external cold, from ligature, or barr- 

VOL. I. d 



26 ELEMENTS OF SURGERY. 

dage, or to tliat which proceeds from any known and vi- 
sible cause, and this as well in its attack as in its pro- 
gress. In some few instances, it makes its appearance 
with little or no pain; but in by much the majority of 
these cases, the patients feel great uneasiness tlirough 
the whole foot and joint of the ankle, particularly in the 
night, even before these parts show any mark of dis- 
temper, or before there is any other than a small dis- 
coloured spot on the end of one of the little toes. 

It generally makes its first appearance on the inside, 
or at the extremity of one of the smaller toes, by a small 
black, or bluish spot: from this spot the cuticle is al- 
"Ways found to be detached, and the skin under it to be of 
a dark red colour. 

If the patient has lately cut his nails, or corn ; it is 
most frequently, though very unjustly set to the account 
of such operation. 

Its progress in different subjects and under different 
circumstances, is different; in some it is slow and long 
in passing from toe to toe, and from thence to the foot 
and ankle; in others its progress is rapid and horribly 
painful : it generally begins on the inside of each small 
toe, before it is visible either on its under or upper part, 
and when it makes its attack on the foot, the upper part 
of it first shows its distempered state, by tumefaction, 
change of colour, and sometimes by vesication, but 
wherever it is, one of the first marks of it is a separation 
or detachment of the cuticle. 

Each sex is liable to it; but for one female m whom 
I have met with it, I think i may say, that I have seen 
it in at least twenty males. I think also that I have 
much more often found it in the rich and voluptuous, than 
in the labouring poor: more frequently in great eaters, 
than free drinkers. It frequently happens to persons 
advanced in life, but it is by no means peculiar to old 



ELEMENTS OF SURGERY. g-v 

age. It is not, in general, preceded or accompanied 
by apparent distemperaturc either of the part, or of the 
habit. I do not know any particular kind of constitution 
which is more liable to it than another ; but as far as my 
observation goes, I think that I have most frequently ob- 
served it to attack those, who have been subject to flying 
uncertain pains in their feet, which they have called 
gouts, and but seldom in those who have been accus- 
tomed to have the gout regularly and fairly. It has, by 
some been supposed to arise from an ossification of ves- 
sels; but for this opinion I never could find any founda- 
tion but mere conjecture. 

The common method of treating this distemper is, by 
spirituous fomentations, cataplasms actually and poten- 
tially warm, by dressings of the digestive kind, as they 
are called, animated m ith warm, pungent oil and balsams, 
&c. and, internally, by the Peruvian bark. 

I wish I could say that this, which, with little altera- 
tion, has been the general practice, had been most fre- 
quently successful; but I am, from long and repeated 
experience, obliged to say that it has not. 

I am sensible, that many of my readers will be sur- 
prised at my affirming, that the Peruvian bark will not 
stop a mortification, a distemper in which for some years, 
it has been regarded as specific ; but I must beg not to be 
misunderstood; I mean to confine my observation and 
my objection to this particular species of mortification, 
which I regard as being sui generis : and under this re- 
striction I must repeat, that I have seldom, if ever seen 
the bark successful: in all other cases, wherein it is used 
or recommended, no man has a higher opinion of it; but 
in this I cannot give it a praise which it does not deserve. 

" I believe I may venture to say, that I have tried it as 
fairly, as fully, and as variously as any man has or can : 
I have given it in the largest quantities, at the shortest 



g8 ELEMENTS OF SURGERY. 

intervals, and for the longest possible space ; that is, as 
long as the patients life would permit. I have given it 
by itself in decoction, extract, and substance: I have 
combined all these together: I have joined it with nitre, 
sal. absynth. with snake-root, with confect. cardiac, with 
volatile salts, and with musk, as different circumstances 
seemed to require, or admit : I have used it as fomenta- 
tion, as poultice, as dressing: I have assisted it with 
every thing which has been usually thought capable of 
procuring, or assisting disjestion ; still the distemper has 
continued its course, perhaps a little more slowly, but 
still it has ended in death. 

" I am sorry to rob one of our great medicines of any 
part of its supposed merit, but as on the one hand, its 
claim, in this instance, is unjust, and as on the other, I 
hope to add as much to the character of another, the res 
medica will be no sufferer. 

" Some time ago, I had a patient labouring under this 
complaint, who from antipathy, obstinacy, or some other 
cause, could not be prevailed on to take bark in any form 
whatever. I made use of every argument but to no pur- 
pose: fomentation, poultice, and the usual dressings 
were applied in the usual manner; the disease advanced 
some days more, some days less, and at the end of a 
fortnight, the small toes were all completely mortified; 
the great one became blackish, the foot much swollen, 
altered in colour, and the disease seeming to advance 
with such hasty strides, that I supposed a very few days 
would determine the event. The pain in the foot and 
ankle was so great, and so continual, as totally to de- 
prive the patient of sleep. On this account, and merely 
to procure some remission, I gave two grains of opium 
at night, which not having the derired effect, I repeated 
it in the morning. Finding, during the following day, 
some advantage, I repeated the same dose night and 



ELEMENTS OF SURGERY. gg 

morning, for three days ; at the end of which time the 
patient became quite easy, and the appearances on the 
foot and ankle were visibly more favourable. Encouraged 
by this, I increased the quantity of the medicine, giving 
one grain every three or four hours, taking care to watch 
its narcotic effect, and to keep the belly empty by glys- 
ters. In nine days from the first administration of the 
opium, all the tumefaction of the foot and ankle totally 
subsided, the skin recovered its natural colour, and all 
the mortified parts plainly began to separate ; in another 
week they were all loose, and casting off', the matter was 
good, and the incarnation florid. During the whole of this 
time I continued the use of the opium, varying its quan- 
tity as circumstances required, but never gave less than 
three or four grains in twenty-four hours. 

" When the sloughs were all cast off*, the bones sepa- 
rated, and I had only a clean sore to dress and heal, I 
gradually left ofl^ the medicine. 

" To relate cases which are nearly, or at least materi- 
ally similar, is of no use : I shall therefore only say, that 
every opportunity, which I have had since of making the 
experiment, has still more and more convinced me of the 
value and utility of this medicine, and of its power of res- 
cuing from destruction, persons under this affliction. 

^^ I cannot say that it has never failed me : it certainly 
has ; but then it has been under such circumstances, as 
I think would fairly account for the failure.'' 

In addition to Mr. Potts' account of this species of mor- 
tification, I shall just add, that in the only case of it I 
have ever seen, the application of a blister produced an 
immediate termination of the mortification. 



30 ELEMENTS OF SURGERY. 

CHAPTER VII. 

Of Burns. 

The application of excessive heat to the body, occa- 
sions severe pain, and inflammation. Its consequences 
are more or less serious in proportion to the degree of 
heat applied and the time of its continuance. 

When the degree of heat is not very great it produces 
pain, redness and slight inflammation which subsides 
spontaneously when the heat is removed. A greater de- 
gree of heat occasions more severe pain ; vesications form 
filled with serum and the true skin under these vesicles, is 
much inflamed. If the burn be extensive, fever attends 
and suppuration takes place. If the heat be still more in- 
tense, the life of the part is destroyed. 

As a general remark it may be stated that burns are 
dangerous in proportion to their extent. A burn which 
destroys the life of a small part of the body, will produce 
but little effect on the constitution, whilst an extensive 
burn, even if very slight in degree, will occasion death. 
I once saw a child scalded on the back, from the neck to 
the hips, by falling into a tub of water in which her mo- 
ther was washing clothes ; the heat occasioned a few ve- 
sications, but the inflammation appeared slight, and yet 
on the fifth day the child expired. 

When the heat is so intense as to destroy the life of the 
part, less pain is experienced than in light burns, but 
when the eschar begins to be separated by the absorbents 
the pain is augmented ; very little pain appears to be suf- 
fered by those who are scalded, and die a few hours after 
the accident. In one such instance, I have known the 
patient to complain of nothing but extreme coldness. In 



ELE>fENTS OF SURGERY. gj^ 

these cases, drowsiness and coma frequently attend. 
Burns which affect parts essential to life, generally termi- 
nate unfavourably. Burns on the head often occasion 
death, by affecting the brain. When the larger joints are 
burned, there is great danger from the violent inflamma- 
tion which follows. 

Treatment. There is no branch of surgery on which 
a greater diversity of opinion and of practice exists than 
in the treatment of burns ; remedies apparently opposite 
in their nature succeed in the hands of different practi- 
tioners, and whilst one surgeon strenuously recommends 
the use of ice and cold water, another proposes an appli- 
cation of hot spirit of turpentine. 

A late writer on this subject, Mr. Kentish, who has 
had very extensive opportunities of applying his princi- 
ples, declares that the stimulating plan of treatment is 
most successful, and he advises the constitution to be sti- 
mulated with opium and ardent spirits, and the part af- 
fected to be dressed with a liniment composed of spirits of 
turpentine and basilicon. The theories which have led 
Mr. Kentish to this practice, are by no means satisfac- 
tory, though the local application he has recommended is 
extremely valuable. 

The method which is found to succeed best by the sur- 
geons of this country, is to attend as in all other cases 
to the state of the constitution, and to accommodate the 
general remedies to it. If there be great pain, opium is 
to be administered. If considerable fever arise, blood- 
letting and evacuating means are to be used. If on the 
contrary, weakness and want of action appear to require 
them, stimulating remedies must be resorted to. 

As a local application to a burn I have found nothing 
so generally successful as the ointment recommended by 
Mr. Kentish. The common basilicon thinned by being 
mixed with the oil of turpentine, forms a liniment, which 



32 ELEMENTS OP SURGERY. 

when spread on rags and applied to the burned surface, 
occasions great relief from pain, and hastens the forma- 
tion of new parts. Mr. Kentish premises to this dress- 
ing, a lotion with brandy, or hot oil of turpentine, or hot 
alkohol. This is in general unnecessary, and the liniment 
may be applied without delay, and at any period within a 
few days after the accident. 

It is not to be denied that cases occur in which this ap- 
plication so generally successful produces pain and in- 
creases inflammation. In some instances, however, this 
has arisen from a want of caution in the application. The 
surgeon, or his nurse, has been careless enough to apply 
the stimulating ointment to the sound skin, where it inev i- 
tably occasions much inflammation and pain. To obviate 
this inconvenience tj^e plasters should be cut into small 
portions and applied to the burned surface only. 

If, notwithstanding this caution, the liniment excites 
pain and inflammation, it must be removed and another 
application substituted. A great variety have been used. 
Vinegar in many cases ajQTords great relief; lime-water 
mixed with oil is a very soothing application ; scraped 
potatoes, a linseed poultice, lead water, are all useful in 
different instances, and if one should not afford relief, the 
others may be tried.* 

The ulcers left by burns have some peculiarities. 
They shoot out fungous gradulations which do not rea- 
dily cicatrize, and when these ulcers do heal, they con- 
tract so much, as in many cases to occasion great distor- 
tions. 

To arrest the growth of fungus, prepared chalk 
should be sprinkled over the sore, and if this be not suf- 
ficiently powerful, burnt alum, or the common escharotic 
applications may be used. 

• Ice has been strongly recommended by Sir James Earl; it alleviates pftin 
and may be applied in bladders over the other dressing's. 



ELEMENTS OF SURGERY. 33 

To prevent deformity from the union of parts which 
ought not to adhere, we should be extremely cautious 
whilst the sores are healing, to interpose plasters between 
them, and by applying splints and bandages to preserve 
them in a proper posture. From neglect of this caution 
great mischief has often arisen. I have seen the chin 
of a boy adhering firmly to his breast; by which 
his mouth was kept constantly open, and his whole ap- 
pearance was greatly deformed. The fingers when se- 
verely burned, are particularly apt to adhere together. 
When this unfortunately happens, we must cautiously 
dissect them loose, and prevent their re-union by proper 
dressings. 



VOL. I. 



34 ELEMENTS OF SURGERY. 

CHAPTER VIII. 

The Effects of Cold. 

The power of resisting the effects of cold by preserv- 
ing a temperature nearly similar in all changes of the at- 
mosphere, is one of the characteristics of living matter. 

The human body possesses this power in a very great 
degree, and like all its other faculties, it is augmented by 
habit. The inhabitants of northern countries are subject- 
ed occasionally to degrees of cold which would unques- 
tionably destroy the natives of tlie torrid zone. The de- 
gree of cold which may be endared without loss of life, 
cannot in the human subject be ascertained.* 

In hospital practice and among the poor, the surgeon 
frequently finds toes and fingers, feet and hands, slough- 
ing off in consequence of exposure to cold. He is not often 
called until it is too late to prevent this effect. When he 
is, the great object is to restore the warmth of the parts 
very gradually. A limb has been frozen perfectly stiff, 
and by being rubbed in snow, afterwards immersed in 
cold water, and then very gradually warmed, its life has 
been preserved. The sudden application of heat never 
fails to occasion inflammation, and mortification very 
quickly follows. After the temperature has been gradual- 
ly raised, and action and sensation are perceived, frictions 

* A woman in a fit of intoxication was overtaken in a snow storm. *« The 
snow accumulated over her to the heigiit of about six feet, a sort of hollow 
cone being left from her head to the surface, through which breathing was 
performed ; from this situation she was removed, after having laid eight days 
in the snow." ■ Her life was preserved, tliough she lost great part of her feet 
Other instances are recorded of long exposure to intense cold, without fatal 
consequences. Our present subject is more particularly tlie effects of its local 
application. 



ELEMENTS OF SURGERY. 35 

with flannel wet with ardent spirit are to be used. The 
patient should then be placed in bed and kept warm ; 
perspiration is to be produced by warm drinks, and by 
"keeping him perfectly at rest, the ill effects will speedily 
subside. 

When mortification occurs, it has been my practice for 
several years to apply blisters, with a view to hasten the 
separation of the dead parts, and the ulcers left I have 
found to heal very soon when treated with basilicon ren- 
dered stimulating by the addition of a little spirits of tur- 
pentine.* 

Chilblain, is a local inflammation situated generally 
upon the heels, toes and fingers, but sometimes upon the 
nose and ears, resulting from exposure to cold. This in- 
flammation varies in degree; when moderate, a redness 
is observed upon the skin, attended with heat and itch- 
ing, which after a time, spontaneously subsides. In a 
greater degree the swelling is larger, of a deeper red co- 
lour, and sometimes purple, or dark blue; the heat, 
itching, and pain are very great. Sometimes small vesi- 
cles arise, which burst and occasion very obstinate ulcers. 
In the most violent cases mortification occurs, preceded 
by the usual vesications containing a dark coloured fluid. 

Chilblains arise most frequently from exposure of the 
parts to sudden and great vicissitudes of temperature. 
They occur oftenest in persons accustomed to indulgence, 
in women and children. 

They generally make their appearance in the winter, 
disappear during the summer, and return the succeeding 
winter. Some persons suffer most from them during the 
autumn, others not until spring; sometimes they continue 

• In cases of suspended animation from cold, there is no necessity for the 

very gradual application of heat; on the contrary, it is recommended to bring' 

the patient into a warm room and rub him with flannels. His feet and legs are 

to be immersed in tepid water, and bladders filled with it are to be applied to 

• the thorax. 



gfi ELEMENTS OV SURGKRV. 

a few days, or weeks, and sometimes during tlie whole 
winter. When violent the patient is unable to move 
about, and is aflfected with considerable fever. When 
suppuration occurs, the bone becomes carious, and even 
death has followed the irritation of a chilblain. 

To prevent the formation of chilblains in young per- 
sons, they should be accustomed to wash in cold water, 
and not to be much in very warm rooms, especially 
avoiding sudden changes from cold to heat, or the reverse. 

The remedies for chilblains vary according to the de- 
gree of inflammation ; the several remedies for inflamma- 
tion however, do not relieve the pain and itching which 
attend this complaint, and one thing it is important to 
know, which is, that the remedies most successful in one 
case, produce no effect upon another; when inefficient 
therefore, they must be varied. In some cases great 
relief is obtained from lotions of a spirituous nature, 
alkohol, laudanum, brandy, and the like, and in others 
poultices afford most relief. Leeches are often useful 
where the inflammation is so violent as to produce fever j 
cold water or snow applied to the part, sometimes pro- 
duces great relief; it should be repeated several times in 
the course of the day, and continued until the pain and 
itching abates. A bath of quicklime prepared by throw- 
ing a piece of fresh burnt lime as large as a man's fist 
into a quart of water, is recommended by Richter as a 
valuable remedy ; the affected part is to be immersed in 
this bath, and kept in it half an hour every morning and 
evening. 

Oil of turpentine affords in many cases great relief. 
Balsam copaiva, basilicon ointment, tar ointment, and 
various other resinous applications are found useful. 

When chilblains ulcerate, they are to be treated as 
ulcers from other causes. When mortification takes place, 
poultices are to be applied until the sloughs separate, and 
then the sore is to be dressed in the usual manner. 



ELEMENTS OF SURGERY, w 

CHAPTER IX. 

Of Wounds. 

A WOUND may be defined, a recent solution in the con- 
tinuity of a part communicating externally, and produced 
by mechanical violence. 

Wounds differ in their nature and appearances from 
an endless variety of circumstances. They admit, how- 
ever of a general division into Incised, and Contused, 
the latter including punctured, lacerated, and gun-shot 
wounds. Incised wounds are made with a sharp cutting 
instrument, and the neighbouring parts sustain no injury. 
Contused wounds are those in which the surrounding 
parts are bruised and injured. 

OF incised wounds. 

When these are of small extent, and made in fleshy 
parts, unaccompanied by a division of any considerable 
blood-vessel, the surgeon by approximating the sides of 
the wound and retaining them in contact, enables them to 
unite, and Ihey very speedily heal. All incised wounds, 
however, are attended with some loss of blood, and this 
is in many cases so great, as to form the chief danger of 
the case; as there is no subject of more importance to the 
surgeon than that of hemorrhage, it will be proper in this 
place to offer some remarks upon it. 

OF HEMORRHAGE. 

In order to ascertain the natural process by which the 
bleeding from a wound is arrested, it is requisite to at- 
tend to the phenomena which follow the opening of large 
blood-vessels. It is now nearly a century since Mr. 



38 ELEMENTS OF SURGERY. 

Petit commenced the investigation of the present subject, 
and since his time a variety of theories have been advanc- 
ed, to explain the natural means by which the bleeding 
from divided arteries is stopped. Dr. Jones in a late 
publication has collected into one view these various and 
discordant doctrines; has selected from each what ap- 
peared founded upon fact, and by very numerous and in- 
teresting experiments, seems to have gone far in develop- 
ing the truth. 

If the vessel opened be a large artei*y, an immediate 
jet or stream of blood is perceived ; this blood is of bright 
scarlet colour, and issues, not in a regular current, but per 
saltum, every contraction and dilatation of the vessel pro- 
pelling it with alternately greater and lesser velocity.* 

'^ An impetuous flow of blood, a sudden and forcible 

* To comprehend this subject fully, it is necessary to recollect some circum- 
stances connected with the anatomy of arteries, which we shall here very briefly 
state. 

" The coats of an artery are three ; the internal is extremely thin and smooth, 
it is elastic and firm in the longitudinal direction, but so weak in the circular as 
to be very easily torn by the slightest force applied in that direction. It is vascular 
and capable of inflaming " 

The middle coat is composed chiefly of muscular fibres, arranged in a circu- 
lar manner ; they differ from common muscular fibres in being more elastic. 
As this middle coat has no longitudinal fibres, the circular fibres are lield together 
by a slender connexion, -which yields readily to any force applied iti the circumference 
of the artery, 

" The external coat is remarkable for its whiteness, density, and great elasti- 
city. IVhen an artery is surrounded by a tight ligature, its middle and internal 
coats are as completely divided by it as they could be by a knife, -wldlst the external 
coat remains entire." 

" Besides these proper coats all the arteries in their natural situations are 
connected by means of the fine cellular substance with surrounding membrane- 
ous sheaths. If an artery be divided, the divided parts, oiuingto their elasticity, re- 
cede from each otlier, arid the length of the celhdar substance, connecting the artery 
■toith the sheath, admits of its retracting a certain -way -within the sheath." 

" Arteries are furnished with, arteries, veins, absorbents, and nerves, a struc- 
ture -which makes them s^isceptible of every change to which living parts are sub- 
jected in common ; enables them to inflame -when injured, and to pour out coagiUating 
lymph by ivhich the injury is repaired, or the tube pertncmently closed." — (Jones.) 



ELEMENTS OF SURGEKY. gg 

retraction of the artery within its sheath, and a slight con- 
traction of its extremity, are the immediate and almost 
simultaneous effects of its division. The natural impulse 
however with which the blood is driven on, in some mea- 
sure counteracts the retraction and resists the contract- 
tion,* of the artery, the blood is effused into the cellular 
substance ])etween the artery and its sheath, and passing 
through the canal of the sheath which had been formed 
by the retraction of the artery, flows freely externally, or 
is extravasated into the surrounding cellular membrane, 
in proportion to the open or confined state of the wound. 
The retracting artery leaves the internal surface of the 
sheath uneven by lacerating or stretching the cellular 
fibres that connected them. These fibres entangle the blood 
as it flows, and thus the foundation is laid for the forma- 
tion of a coagulum at the mouth of the artery, and which 
appears to be completed by the blood as it passes through 
this canal of the sheath, gradually adhering and coagu- 
lating around its internal surface, until it completely fills 
it up from the circumference to the centre.'' (Jones.) 

The diminished force of the circulation of the blood, 
its speedy coagulation, and its extravasation into the sur- 
rounding cellular texture, are circumstances wliich con- 
tribute greatly to put a stop to the hemorrhage. The co- 
agulum which acts as a plug to tlie open orifice, is situ- 
ated not actually within this orifice, but within its sur- 
rounding sheath, and as it is outside of the vessel. Dr. 
Jones has called it external; a coagulum however, is 
found within the arterial tube, as high as the nearest col- 
lateral branch, this is not suflicient in volume to fill up the 
vessel and adheres to the artery no where except at the 
divided extremity; this clot is called the internal coa- 
gulum. 

• The retraction refers to the diminished lengthy and tlie contraction to the 
diminished volume or diameter of the artery. 



40 ELEMENTS OF SURGElt\. 

The wounded artery afterwards inflames and its ves- 
sels (like those of any other inflamed part) secrete co- 
agulating lymph in sufficient quantity to fill up the ex- 
tremity of the artery between the external and internal 
coagula. This lymph appears to unite these coagula to- 
gether, and adheres firmly all round to the internal coat 
of the vessel. It is this secreted lymph which constitutes 
the permanent barrier to the flow of blood, and this bar- 
rier is rendered stronger by a contraction of the wounded 
extremity of the vessel, and by an effusion of lymph be- 
tween its coats, and into the surrounding cellular sub- 
stance, by which these parts become incorporated to- 
gether very firmly. If the wound in the integuments re- 
mains open, the effused lymph connects the artery to the 
subjacent and lateral parts, and gives it a new covering 
which entirely excludes it from the outward wound. 

The same circumstances are also remarkable in the 
portion of the vessel most remote from the heart. Its ori- 
fice is usually more contracted and its external coagulum 
smaller than the one which attaches itself to the other cut 
end of the artery. 

The impervious extremity of the artery no longer al- 
lowing blood to circulate tlirough it, the portion which 
lies between it and the first lateral branch, gradually 
contracts till its cavity is completely obliterated, and its 
tunics assume a ligamentous appearance; the external 
coagulum which in the first instance had stopped the he- 
morrhage is absorbed in a few days, and the coagulating 
lymph effused around it, by which the parts were thick- 
ened is gradually removed,so that they resume their cel- 
lular structure. 

At a still later period the ligamentous portion is re- 
duced to a filamentous state, so that the artery is as it 
were completely annihilated from its cut end to the first 
lateral branch ; long however before this final change is 



ELEMENTS OF SURGERY. <^| 

accomplished, the inosculating branches have become con- 
siderably enlarged, so as to establish a free communica- 
tion between the disunited parts of the main artery. 

Wlien an artery has been divided at some distance 
h'om a lateral branch, three coagula are formed : one of 
blood externally, which shuts up its mouth; one of 
lymph, just within the extremity of its canal, and one of 
blood, within its cavity, and contiguous to that of lymph. 
But, when the artery has been divided near a lateral 
branch, no internal coagulum of blood is formed. 

The external coagulum is always formed, when the 
divitled artery is left to nature ; not so however, if art 
interferes, for under the application of the ligature it can 
never form. If agaric, lycoperdon, or sponge be used, 
its formation is doubtful, depending entirely upon the de- 
gree of pressure that is used ; but, the internal coagulum 
of blood will be equally formed, whether the treatment 
be left to art or nature, if no collateral branch is near the 
truncated extremity of tiie artery ; and lastly, efliised 
lymph, which, when in sufficient quantity, forms a dis- 
tinct coagulum, just at the mouth of the artery, M'ill be 
always found, if the hemorrhage is permanently sup- 
pressed. 

When, instead of a complete division of an artery, it is 
only partially divided or punctured, the cessation of 
bleeding is not so easily effected by natural means ; hence 
it was the custom of the ancients in such instances to di- 
vide completely a punctured artery. 

Mr. Petit appears to have given the best account of the 
process by which the bleeding from arteries jjartially di- 
vided are stopped. Dr. Jones, after a great number of 
experiments performed with a view to elucidate this sub- 
ject, confesses that he has little to add to Mr. Petit's ac 
count. 

The blood is effused into the relhilar substance, be- 

voi,. I. 7 



4@ Er.F.MENTS OF SURGERY. 

tw en the artery and its sheath, for some distance, botk 
above and below the wounded part ; and when the parts 
are examuied, a short time after the hemorrhage has 
completely stopped, we find a stratum of coagulated blood 
between the artery and its sheath, extending from a few 
inches below the w ounded part, to two or three inches 
above it, and somewhat thicker, or more prominent over 
the wounded part than elsewhere. 

Hence, rather than say the hemorrhage is stopped by 
a coagulum, it is more correct to say, that it is stopped 
by a thick lamina of coagulated blood, which, though 
somewhat thicker at the wounded part, is perfectly con- 
tinuous with the coagulated blood lying between the ar- 
tery and its sheath. 

When an artery is punctured, the hemorrhage imme- 
diately following, by filling up the space, between the 
artery and its sheath, with blood, and consequently dis- 
tending the sheath, alters the relative situation of the 
puncture in the sheath to that in the artery, so that they 
are not exactly opposite to each other ; and by that means 
a layer of blood is confined by the sheath over the punc- 
ture in the artery, and, by coagulating there, prevents any 
further effusion of blood. 

But this coagulated blood, like the external coagulum 
of a divided artery, affords only a temporary barrier to 
the hemorrhage: its permanent suppression is effected by 
a process of reparation, or of obliteration. 

It has been doubted by many respectable surgeons 
whether arteries when wounded, can heal without an ob- 
literation of the cavity of the vessel, in such a manner 
as to carry on the circulation of blood. The experiments 
of Dr. Jones upon a number of animals prove that in 
brutes this very generally happens, when the artery is 
wounded only to a small extent ; the cicatrization in these 
cases is so complete, that no vestige of the wound can be 



ELEMENTS OF SURGERY. <^3 

perceived, eithe'i* on the external or internal surface of the 
artery, and that even oblique and transverse wounds 
when they do not exceed one-fourth of the circumference 
of the vessel, are filled up, and healed by an effusion of 
coagulating lymph from their inflamed lips, so as to oc- 
casion little or no obstruction to the canal of the artery. 
It may still be questioned whether in the human body the 
same mode of union is effected. 

When an artery of considerable magnitude is punctur- 
ed, even by a sharp lancet, the circular fibres of the artery 
in most cases contract so much, as to separate the sides of 
the wound to a considerable distance from each other, it 
appears as if a piece of the vessel had been actually re- 
moved.* To effect the reparation here, acoagulum forms 
as explained by Mr. Petit, inside of the artery, and ex- 
tends through the wound, to a coagulum situated on the 
outside of the vessel,! in this manner the aperture is tem- 
porarily closed, and the permanent closure depends on 
the secretion of coagulating lymph, which is poured out 
in considerable quantity, and in many cases (probably a 
large majority of cases) obliterates the arterial tube, but 
in some instances the artery heals as in the experiments 
upon brutes related by Dr. Jones, and then the cicatriza- 
tion is completed without a destruction of thS arterial 
cavity. Mr. Petit records an instance of this, and in 
professor Scarpa's learned treatise on Aneurism, I find 
another very decided instance in which this mode of 
union was effected in the brachial artery of a man. 
Scarpa denies that when the artery heals in this manner 
the cure is radical. He supposes the vessel weaker at 

* Such is the common opinion, but I have seen several cases of punctured 
arteries, in which no gaping was eviilent, tlie wound being a mere sht, the 
sides of which were nearly or closely in contact, though they had not united. 
As this has been the ciuse in all the punctured arteries I have seen, I cannot 
doubt that it very often happens. 

f The inner clot hc ccdls " bouchon^" a cork, or plug, the external is called 
" couvercle." 



44 ELEMENTS OF SURGERY. 

the cicatrix than at any other part. A case of wounded 
brachial artery which healed without an obliteration of 
its canal may be found in the New York Med. and Phil. 
Journal, No. 4. 

Having thus stated the natural process by which a 
wounded artery is repaired, we may next mention that 
these powers of reparation appear to exist in an inverse 
ratio to the size of the vessel, small vessels healing much 
more readily than large ones. 

In incised wounds the flow of blood is always much 
greater than in contused wounds of similar parts. The 
effect which laceration has in preventing hemorrhagy 
may be estimated from a case related by Cheselden, in 
which a miller's arm was torn off, together with the 
scapula from the chest, of course some of the largest 
arteries of the body were divided, and yet no fatal he- 
morrhagy ensued. I have known a boy's arm ground 
off in a mill within a few inches of the shoulder, and so 
little bleeding resulted, as scarcely to stain his clothes. 
Dr. Physick has attributed this effect of contusion, 1st, 
To the diminished power of the vessels to carry on the 
circulation. In an incised wound the vessels are only 
injured at the divided surfaces; in a contused wound 
they are injured to a considerable distance and therefore 
circulate the blood less rapidly. Sdly, In a contused 
wound the blood escapes less readily by the external 
opening, and becomes extravasated into the cellular tex- 
ture making lateral pressure upon the blood-vessels.^ 
3d]y, The blood coagulates much more promptly in con- 
tused than in incised wounds, and this coagulation is a 
powerful barrier to the escape of the blood. The ex- 
tremities of divided vessels are often actually killed by 
the contusion, and blood, when in contact with dead 

* The lateral pressure is increased by ecchymosis, from a number of rup- 
tured blood-vessels which have no external communication, and bleed into the 
interstices of the neighbouring parts. 



ELEMENTS OF SURGERY. 



45 



mattev speedily coagulates. The coagulatit)n of blood 
in the divided extremities of the vessels, forms another 
obstacle to hemorrhage. 

TREATMENT OF INCISED WOUNDS. 

In the treatment of an incised wound, the first object 
is to stop the bleeding. In many cases a wound bleeds 
profusely at first, and gradually stops without any atten- 
tion from the surgeon. In some cases moderate pressure 
upon the wound by holding its sides in contact, puts a 
stop to the flow of blood, and this, if no large artery be 
obvious, should always be tried. If, upon removing the 
pressure the wound continues to bleed, or if previously 
to trying this, a bleeding artery is observed, it must be 
taken up upon the point of a tenaculum, and a ligature 
applied round it. 

If the bleeding is so great as to prevent an accurate 
inspection of the wound, so that the artery cannot be per- 
ceived, pressure must be made upon the trunk of the 
main artery which supplies the parts with blood. This 
pressure may be made with a finger, or if the wound he 
seated in an extremity, with a tourniquet; that of Petit 
is to be preferred for simplicity and facility of applica- 
tion to all others.* When the tourniquet is to be ap- 
plied, it must be placed above the knee or elbow, be- 
cause, as there is only one bone in these parts, a circular 
bandage will compress all the vessels of the limb. After 
the tourniquet is applied and screwed so tight as to in- 
terrupt the circulation, the surgeon is to wash the wound 
with a sponge and warm water, and then, whilst his eye 
is fixed on it, the screw is gradually loosened, and the 
divided vessels may be seen by the stream of blood 
escaping from their extremities. 

• I mean the tourniquet in common use, invented by Petit, and improved 
by Freke. 



46 ELEMENTS OF SURGERY. 

It is to be recollected, that if the wound be too high up 
on an extremity for the application of a tourniquet, the 
compression of the vessel may still be effected. The sub- 
clavian artery may be compressed as it lies over the first 
rib, and the circulation in the arm may thus be complete- 
ly prevented, and from pressure in the groin, the trunk of 
the femoral artery ceases to pulsate. In every instance 
where the bleeding does not speedily cease, and the ori- 
fice of the bleeding artery can be seen, it is to be tied up. 
And whenever large arteries are wounded, there is no 
other mode of stopping the hemorrhage to be confided in. 

Dr. Jones having made a number of experiments to as- 
certain the effects of the ligature upon an artery included 
in it, and properly tied, states, that the internal and mid- 
dle coats of the artery are cut through and kept in close 
contact by the ligature ; infiammation supervening they 
adhere and unite firmly. 

There are however some situations in which it is ex- 
tremely difficult to tie up a wounded artery. If a vessel 
be opened in a deep wound of small extent, it becomes 
sometimes necessary to dilate the wound, in order to ex- 
pose it. Sometimes we are able by enclosing in the li- 
gature a portion of flesh through which the artery passes, 
to put a stop to hemorrhage. In other cases the applica- 
tion of lint and moderate pressure effects the purpose 
(but this can only be trusted when the bleeding is from 
small vessels.) The application of stiptics and escharo- 
tics, is nearly out of use among surgeons ; and yet 
cases sometimes occur, in which they may be employed 
with advantage, as when the bleeding vessel is beyond 
the reach of the ligature, and in such a situation, as to 
preclude compression.* I have once known the hot 

• Powdered agaric, flour sprinkled over the surface.by exciting coagulation 
often stops the bleeding, Sp. turpentine, alum, blue vitriol, the mineral acids, 
lunar caustic, 8;c. 84c. &c. 



ELE]\fENTS OF SURGERY. ^ 

iron necessary to put a stop to a most alarming hemorr- 
hage from a large artery in the posterior fauces, which 
had been wounded in extirpating a tumour from the 
mouth. It sometimes happens that a proper posture of a 
limb restrains hemorrhagy. The posture should be one 
in which gravity favours the descent of blood through 
the veins, and retards its motion in the arteries. 

The form of the ligatures used by surgeons is not an 
object of much consequence when the vessels are small ; 
when a large artery however is to be secured. Dr. Jones 
recommends them to be round and very firm ; he states, 
that though a slight force only is necessary to cut through 
the internal and middle coats of an artery, it is better to 
tie the vessel more tightly than is necessary, merely to cut 
through its inner coats, because the cut surfaces will be 
more certainly kept in contact, the separation of the liga- 
ture expedited, and the danger of ulceration spreading to 
the new ly cicatrized part diminished. This direction of 
Dr. Jones, I believe useless, and except in the larger 
arteries, it is quite sufficient to tie the ligature with force 
enough to command the hemorrhage, and even in the 
largest arteries, I believe the direction has frequently in- 
duced surgeons to break their ligatures by unnecessary 
force. 

I would here state, that round bobbin forms an excel- 
lent ligature for the larger arteries, and for smaller ves- 
sels, a number of sewing threads waxed together of a pro- 
per thickness may be used. 

Shortly after the first edition of this work was pub- 
lished, Dr. Physick suggested to the author the pro- 
priety of testing by experiment, the value of an improve- 
ment he had long contemplated in the formation of liga- 
tures — this was accordingly done, and has resulted in the 
substitution of certain animal substances for the materials 
formerly employed. 



48 ELEMENTS OF SUKGERY. 

It has long been a desideratum among surgeons, to be 
able to remove the ligature from a wound after the blood- 
vessel on Avhich it has been applied is healed. Many 
weeks, and in some cases months, have been found to 
elapse before tlie ligature is detached, during all which 
time the sore is prevented from healing, and in some 
cases hectic fever and a fatal termination have resulted. 
There can be no reasonable doubt entertained, that all 
the processes requisite for the complete obliteration of a 
blood-vessel, secured by ligature, are completed in a very 
short space of time, probably in two or three days.* It 
follows that if the ligature applied, be made of materials 
capable of securing the vessel during this space of time, 
and liable to decomposition and solution in the animal 
fluids afterwards, the requisite advantages will be ob- 
tained. Dr. Physick was induced to believe that leather 
would be found to possess these properties ; he had re- 
marked that the strips of adhesive plaster applied over 
ulcers, retained their strength of texture a few hours and 
then became dissolved in the pus discharged from the sore; 
should the leather be found to dissolve too rapidly, there 
were other animal matters which he proposed to substitute. 

The first experiment made to ascertain the correctness 
of these opinions, was the application of a buckskin liga- 
ture to a large artery in a horse. It restrained the bleeding 
and was discharged in a liquid state in two or three days. 

Sometime after this experiment. Dr. Hartshorne em- 
ployed ligatures of animal matter for securing the 
blood-vessels in the human subject. He amputated a leg 
at the Pennsylvania Hospital, and tied up the vessels with 
strips of parchment, which were found to answer ex- 
tremely well. At the first dressing the ligatures were 
found dissolved, and never occasioned any inconvenience. 

* vide Travers' Experiments, in the 6lh vol. Medico-Chir. Transactions. 



ELEMENTS OF SURGERY. 4,<J 

Pursuing tlie enquiry, I performed a number of expe- 
riments with various animal substances, as catgut, parch- 
ment, various kinds of leather, &c. The best method of 
constructing ligatures which I have been able to devise, 
is by cutting French kid leather into strips, from a fourth 
of an inch to half an inch in width, peeling off what is 
called the grainy or coloured, polished surface: the 
strips are then wet and stretched — they gam greatly in 
length and are diminished in breadth by this process; 
and ligatures may be prepared of any requisite strength 
by varying the width of the sti-ips. I have employed 
them jjn amputations, and in a number of the capital ope- 
rations, and never have seen any occasion to regret their 
use, but on the contrary, to consider it one of the most va- 
luable improvements in modern surgery. 

I have not thought it requisite to leave the ligatures 
hanging out of the wound, after accidents or operations, 
but have cut them very close to tlie knot and treated the 
case as if no ligature were employed. In some instances 
union by the first intention has taken place, the ligature 
probably being dissolved and absorbed, at least it has 
never afterwards appeared, but in others suppuration and 
abscess have been produced. 

Since the experiments above cited have been made, I 
find tiiat Mr. Lawrence has proposed to cut off the liga- 
tures after operations, close to the divided vessels. How 
well the practice may succeed where they are composed 
of dural)le materials, future experience may decide, but I 
cannot forbear the expression of a belief, that the animal 
ligatures will supplant all others except in a few particu- 
lar cases which will readily suggest themselves to the 
surgeon. For example, in closing wounds of the abdo- 
men, when they can be taken out at pleasure — in cases 
of hare-lip, &c. 

The leather ligatures are rather more bulky than those 

VOL. f. 8 



go ELEMENTS OF SURGERY. 

made of thread or silk: a little practice, however, will 
enable the surgeon to make them very neatly, and to em- 
ploy them in arming his needles, as conveniently as any 
others. In several cases in which I have amputated 
scirrhus breasts, and have necessarily removed much skin, 
I have from the heat of the weather, been induced to 
dress the patient on the third day, and at this period not 
a vestige of ligature has been observetl, except at the up- 
per part of the wound, when this has been dry, in which 
case the leather is not destroyed so rapidly. 

The femoral is the largest artery I have as yet secured 
with a leather ligature; I should not, however, l^esitate 
to employ one for tying any other vessel in the body 
when necessary. It would be easy by soaking the liga- 
tures in linseed oil; or in certain resinous substances, to 
render them more durable, but I have not found this ex- 
pedient necessary.* 

When the bleeding from an incised wound is arrested, 
the next thing demanding the attention of the surgeon, is 
the removal of all extraneous matter ; the clotted blood, 
dirt, &c. must be carefully washed away, and the sides 
of the wound are then to be approximated and kept in 
contact. The measures to be employed for this purpose 
are strips of adhesive plaster, compresses, bandages, 
and a proper position of the part, rest, and lastly sutures. 

The adhesive plasters are in most cases sufficient, 
when aided by bandages and a proper posture, without 
the use of the needle. The sides of the wound being 
placed in contact, are to be held so by an assistant, and 
the surgeon is to apply strips of plaster spread on linen 
or leather across the wound. These strips should be of 
considerable length, so as to act on a large surface of sound 
skin, and from half an inch to an inch in width. They 

* The first publication on this subject was made by Dr. Physick, in the Eclec- 
tic Repertory, dated July 9tb, 1816. 



ELEMENTS OF SURGERY. 5^ 

i^hould be placed at a small distance one from the other, 
so as to allow the escape of any extiavasated fluid 
through the interstices. If this caution be neglected, and 
the plasters placed so as to cover the whole wound, they 
often convert it into an abscess, by preventing an outlet 
for superfluous blood or serum, and in case of suppura- 
tion the pus is confined, the parts already united are torn 
asunder, and the inflammation is extended. 

If, from the small extent of the wound and other cir- 
cumstances, there is reason to expect its union by the first 
intention, or by the adhesive inflammation, nothing more 
is necessary than to apply a compress of folded linen, or 
a pledgit of dry lint over the adhesive strips, and secure 
them by a few turns of a roller. 

Should there be no good prospect of so speedy a cure, 
and reason to expect suppuration, a pledgit of lint spread 
with simple cerate, and covered with a pledgit of tow or 
folded linen, may be placed over the adhesive strips and 
confined by the many-tailed bandage, or roller; but it is 
of no importance to make any difl^erence of treatment on 
account of the uncertainty respecting the manner in which 
the wound is to heal, and it is best to treat incised wounds 
generally as if the union by the first intention were cer- 
tain. The pledgit of tow or linen which adds somewhat 
to the pressure, and is calculated to absorb any fluid which 
may escape from the wound, may readily be superadded 
if found necessary. 

In all incised wounds the sides should be placed and 
kept as much as possible in contact. There can be no 
application to wounded flesh more natural or proper than 
the flesh from which it has just been violently separated, 
and if it do not adher^to it entirely, yet in all proba- 
bility a very considerable part will, and thus the extent 
of the wound will be lessened. 

The I'cipidity with which incised wounds sometimes 



5% ELEMENTS OF SURGERY. 

unite, is really astonishing to any one not conversant 
with these wonderful powers of nature. I have seen 
a consideriible tumour cut out from the breast, and in 
forty-eight hours a complete union of the wound had 
taken place. The wound may be examined in warm 
weather in forty-eight hours, in winter it is best not to 
disturb the dressings for three or four days. 

If fever and inflammation attend, the usual depleting 
remedies are to be used ; if on the contrary, there be rea- 
son to apprehend tetanus, wine, opium, and a generous 
diet are to be prescribed. 

The blood effused from the wound is in many cases 
the bond of union in incised wounds, but very often this 
is lost and adhesive inflammation supervenes ; in this 
case the secreted coagulating lymph becomes the uniting 
medium, and this is soon assimilated to the wounded 
part, becoming bone, tendon, muscle, or skin, according 
as the wound has been in any of these parts. The cica- 
trix however, differs considerably from the origin.illy 
formed parts. 

Posture is of great consequence in the treatment of 
wounds. The sides of a wound on the anterior part of 
the thigh cannot be kept in contact, unless the leg be 
kept extended upon the thigh ; to aid the surgeon st^l 
more in relaxing the parts, the thigh should be flexed on 
the pelvis. A wound through the tendo acliillis should 
be treated by extending the foot upon the leg, &c. 

Sutures by attending to these preceding directions are 
very rarely necessary; and if possible they ought to be 
dispensed with, as they produce considerable pain, oc- 
casion great and permanent irritation by creating a num- 
ber of punctured wounds, whicl^are kept from healing 
by the ligature left in them ; this ligature passes through 
a part of the original wound, and never f^ils to excite 



J^/iM-'t'f^^i/^ ^<^^'. 



PLATE /. 



# 




fl 



s; 



'T 











'C^m^/gdor Aa/u^^jJiilu/t^ 



■jmii»>^-. 




'/run^/'ywa' r///v/ y^/v 



//y 



ELEMENTS OF SURGERY. Q^ 

suppuration in that part, in addition to these ohjections, 
sutures occasion deformity by increasing the extent and 
Irregularity of the cicatrix. 

Notwithstanding these objections, sutures are some- 
times necessary in wounds of projecting parts, as the 
ears, nose, tongue, lips, scrotum, &c. Sometimes the pe- 
ritoneum is wounded, and in these cases ligatures are ne- 
cessary to keep its edges in contact. In all these instances 
the interrupted, or twisted suture are to be used. The 
interrupted suture consists in making the necessary 
number of stitches with an armed needle, and tying them 
in such a manner as to keep the sides of the wound to- 
gether.* The twisted suture is chiefly used in wounds 
of the lip ; in the annexed plate these sutures are repre- 
sented. In the twisted sutures «two or more pins of sil- 
ver with moveable steel points are passed through the 
flesh, and a ligature twisted round them, so as to con- 
fine the sides of the wound in contact. In treating hare- 
lip, this suture is generally employed. The pins ought 
to be made of smooth silver wire, the extremities of 
which fit into steel points which are taken off when the 
ligature is applied. If these be not at hand, a piece of 
wire filed sharp at the end will answer, but after the liga- 
ture is bound on, the point must be cut off with a pair of 
scissors, or a file. 

When ligatures have been applied upon bleeding ar- 
teries, the ends of them are to be left long enough to pro- 
ject a short distance out of the wound, they are to be 
left out of one of its angles, (the most depending if prac- 
ticable) and the wound treated as we have already di- 
rected. 

When in cases of incised wounds it becomes evident 

* The knots should be on one side ot the wound. It is liglit to have tne 
needle shuped so as to form a regular segment of a circle, and to have two 
■lilting edges continued from the point 



54? ELEMENTS OF SURGERY. 

tbat union cannot be eflfected without suppuration, the 
adhesive plasters, and every pressure, every irritation 
are to be removed, and a soft poultice substituted. 
When suppuration is fairly established and j^ranulations 
begin to form, the means already recommended for re- 
taining the sides of the w^ound in contact, are to be re- 
sumed and a cure will generally be soon effected. 



ELEMENTS OF SURGERY. q^ 

CHAPTER X. 

Of Contused Wounds. 

In contused wounds, besides the simple solution of 
continuity, there is an injury of the adjacent flesh, great- 
er or less according to the nature and violence of the 
force applied. 

Contused wounds ai*e produced by blunt instruments. 
It has already been remarked, that these wounds bleed 
less profusely than simple incisions, and the reasons of 
this difference have been explained. 

The indications of cure are to prevent excessive in- 
flammation, to wait for the separation of the bruised and 
dead flesh, and when suppuration is established and gra- 
nulations form, to approximate and retain in contact the 
sides of the wound. 

The best local application is a boiled bread and milk 
poultice. If inflammatory symptoms run high, blood-let- 
ting is to be directed. If great pain or irritation come on, 
opiates may be given ; should gangrene result, a blister 
is to be applied. 

Lacerated wounds partake of the nature of con- 
tusion, but there is a difference, as their mode of union 
proves. A severely contused wound never heals by the 
first intention, because there is an interposition of clot- 
ted blood and injured flesh, between tlie sound parts, 
whereas I have known half the scalp torn off in a lace- 
rated wound, and the whole of it has reunited by the 
first intention, except the edges which were greatly 
bruised. 

Punctured wounds have considerable depth, and 



56 ELEMENTS OF SURGERY. 

very little external opening : they are made by pointed 
instruments, as a small sword, bayonet, nails, needles. 
They are attended with various consequences, according 
to the nature of the parts injured. In other wounds the 
nature of the mischief is generally apparent ; in punctur- 
ed wounds, the surgeon is unable to ascertain with accu- 
racy the parts which are injured; important nerves, 
blood-vessels or tendinous fasciae are sometimes wounded; 
very violent inflammation often follows a small punc- 
tured wound, and collections of matters are sometimes 
formed, great irritation occasionally occurs, the consti- 
tution suffers and fever comes on. Tetanus is a frequent 
occurrence after punctured wounds, though I have as 
often seen it a consequence of other contused wounds. 
Convulsions, tremour, and nervous affections, are also oc- 
casioned. 

In the treatment of punctured wounds, the first thing 
demanding attention is hemorrhage. If any blood-vessel 
of considerable size have been opened, it must be sought 
for by dilating the orifice of the wound with a probe and 
scalpel; the vessel being exposed in tliis manner, should 
be tied up with a ligature. In some cases, the bleeding, 
at first profuse, gradually ceases, and although from the 
rapidity with which it flowed, there may be reason to ap- 
prehend the puncture of a large artery, yet the patient is 
unwilling to suffer his wound to be dilated in order to se- 
cure the vessel; and it is a fact that such vessels have 
sometimes healed without the interference of art. I have 
been informed of a case in which a very large artery in 
the thigh, probably the femoral,^ was opened by a small 

• I speak thus cautiously because there was no dissection, but I have no 
doubt that the wounded vessel was the femoral artery, because the stream of 
blood was so copious at first as to lead the surgeons present to that opinion 



ELEMENTS OP SURGERY. gy 

sword, and although the stream of blood at first was very 
alarming; yet it soon ceased, and did not recur, until the 
tenth day, when an officious surgeon forced his probe into 
the vessel and the patient died in consequence of the bleed- 
ing; there is great reason to believe that this patient 
would have recovered but for the improper interference 
of his surgeon. Whenever therefore the bleeding ceases 
spontaneously, or after the wound is dressed, the patient 
should be kept still and watched carefully, as a return of 
hemorrhage is to be appn bended. If the puncture be on 
a limb, a tourniquet may be applied and left loose, so that 
an assistant may have it in his power in a moment to put 
a stop to the effusion of blood, until the artery is finally 
secured by a ligature. 

The healing of a large artery, however, is an event sel- 
dom to be trusted to, and tliere is no surgical maxim of 
greater importance than the necessity of tying up all 
wounded arteries when it is practicable. It is only in 
eases where this cannot be done that the surgeon is to 
avail himself of other means for suppressing the hemorr- 
hage. As all such means furnish important resources to 
the surgeon, I shall mention a plan which I have known 
successful in stopping the flow of blood from an artery in 
the foot. The patient was a child in whom several una- 
vailing attempts to tie up the divided vessel had been 
previously made, and the wound was in a state of great 
inflammation. A compress was applied over the trunk 
of the anterior, and another over that of the posterior 
tibial arteries about two inches above the ancle: over 
these a strip of sheet copper was passed round the leg, 
and a tourniquet was applied over the copper ; in this 
way, when the tourniquet was tightened, the tibial arte- 
ries were compressed, and the bleeding ceased, the cop- 
per prevented the tourniquet from compressing any other 
vessel, so that the circulation in the foot was not inter- 

voi^. T. 9 



58 ELEMENTS OF SURGERY. 

rupted. Ill a few days the wound healed without any 
recurreiice of hemorrhage. Probably in some analogous 
cases similar measures may be found successful. 

When punctured wounds contain foreign substances 
which are easily felt, they may be dilated sufficiently to 
allow the extraction of these substances, but in most in- 
stances it is best to permit them to be discharged by sup- 
puration. 

When convulsions, or great nervous irritation follow, 
the dilatation of a punctured wound frequently puts an im- 
mediate stop to these symptoms ; a small incision upon 
a probe passed into the puncture, will suffice for this pur- 
pose. 

When punctured wounds occur in extremely hot wea- 
ther, it is safest to enlarge them by the scalpel, or to apply 
stimulating substances to excite inflammation; there is 
reason to believe that tetanus has in this way been often 
prevented. 

Erysipelatous inflammation in some instances follows 
punctured wountls, especially of the scalp ; an enlarge- 
ment of the wound has been found useful in these cases, 
and a blister should be applied over the inflamed parts. 

These are the principal circumstances in punctured 
wounds, which call for dilatation ; when suppuration is 
established, if matter be formed and confined, an outlet 
must be made for it as in any other case. The practice of 
dilating indiscriminately all punctured wounds is highly 
reprehensible. A soft poultice is the best local applica- 
tion. If the pain be great, opium may be administered, 
and if fever or inflammation run high, bleeding and de- 
pleting remedies may become necessary. They are al- 
ways, hoAvever, and particularly in hot weather, to be 
prescribed with caution, as they certainly render the sys- 
tem more liable to tetanus; punctured wounds some- 
times unite by adhesive inflammation; but if extensive 
they generally suppurate. 



ELEMENTS OF SURGERY. ^(j 



CHAPTER XI. 

Of Gunshot Wounds. 

Since the application of gunpowder to the purposes of 
Avar, a new class of wounds has attracted the attention of 
surgeons, the nature and peculiarities of which have only 
within a few years been well understood. 

^^ Gunshot wounds are made by the forcible projection 
of hard obtuse bodies, the greatest number of which are 
musket balls, 

^^ They vary according to the kind of body projected, 
the velocity of the body, and the nature and peculiarities 
of the parts injured. The kind of body projected, is prin- 
cipally musket balls, sometimes cannon balls, sometimes 
pieces of broken shells, and very often on board of ship, 
splinters of wood. The effects of cannon balls on different 
parts of the ship, are the principal causes of wounds in the 
sailor, for a cannon ball must generally pass through the 
timbers of the ship before it reaches him ; a greater num- 
ber will be wounded by the splinters thus torn off, than 
by the ball itself. The wounds occasioned by these splin- 
ters, differ in no respect from contused and lacerated 
wounds from other causes. 

" Gunshot w ounds are in general contused wounds, 
from which contusion there is most commonly a part of the 
solids surrounding the wound deadened, as the projecting 
body forced its way through these solids, which is after- 
wards thrown off in form of a slough, and whicli prevents 
such wounds from healing by the first intention, or by 
means of the adhesive inflammation, from which circum- 
stance most of them must be allowed to suppurate. This 
does not always take place equally in every gunshot 



60 ELEMENTS OF SURCERY. 

wound, nor in every part of the same wound; and the 
difference commonly arises from the variety in the velo- 
city of the body projected; for we iind in many cases, 
where the ball has passed with little velocity, which is 
often the case with balls, even at their entrance, but most 
commonly at the part last wounded by the ball, that the 
wounds are often healed by the first intention. 

^' Grunshot \\ ounds, from the circumstance of commonly 
having a part killed, do not generally intlame so readily 
as those from other accidents ; this backwardness to in- 
flame, \\\\\ be in the proportion that the quantity of dead- 
ened parts bear to tlie extent of the wound. 

^^From the circumstance of a part being deadened, a 
gunshot wound is often not completely understood at first; 
for it is at first, in many cases, impossible to know what 
parts are killed, whether bone, tendon, or soft part, until 
the deadened part has separated, which makes it a much 
more complicated wound than at first was known or imagin- 
ed ; for it very often happens, that some viscus, or a part of 
some viscus, or a part of a large artery, or even a bone, has 
been killed by the blow, which does not show itself till the 
slough comes away. If for instance, it is a part of an intes- 
tine that has received a contusion, so as to kill it, and which 
is to slough, a new symptom will most probably appear 
from the sloughs being separated, the contents of the in- 
testine will most probably come through the wound ; and 
probably the same thing will happen when any other con- 
taining viscus is in part deadened; but those cases will 
not be so dangerous, as if the same loss had been pro- 
duced at first, for by this time all communication will be 
cut off between the containing and contained parts ; nor 
will it be so dangerous as when a considerable blood-ves- 
sel is deadened; for in this case, when the slough comes 
off, the blood, getting a free passage into the wound, as 
also out of it, probably death will immediately follow. IC 



ELEMENTS OP SURCFHY. Qi 

this artery is internal, nothing can he done ; if in an ex- 
tremity, the vessel may generally he taken up. When the 
bone is deadened, an exfoliation must take place." 

The velocity with which the ball passes has a great 
influence on the circumstances of these accidents. If the 
velocity be small, there is not so great a chance of their 
being compounded with fractured bones ; but if the ve- 
locity be sufficient to break the bone it hits, the bone will 
be much more splintered than if the velocity had been 
very considerable, for where the velocity is very great, 
the ball as it were, takes a piece out. In a very hard 
bone the splinters will be most numerous. The direction 
of a ball is influenced by the celerity of its motion. If it 
move with but little force, it is easily altered from its 
straight direction, by a bone ; where the velocity is great- 
est, the course is most direct. 

The greater the velocity of a bullet, the greater will 
be the extent of the deadened parts, consequently the 
slough is always greater at the entrance than at the -exit 
of a ball, and in some cases the part at vvliich it passes 
out, heals by the first intention or by suppurative inflam- 
mation without casting off any slough. 

Gunshot wounds like all other contused wounds, bleed 
less than simple incisions, the explanation of this has 
already been offered. If, however, large vessels are 
killed by the ball, when the sloughs separate there will 
be great danger of hemorrhage from the opening formed 
in the artery. 

There is very frequently extraneous matter contained 
in gunshot wounds, as the bullet carries in with it all 
the clothing which had been on the wounded part, and 
often remains itself in the wound, much altered in foi-m 
from the effects of bones upon it. I have seen a bullet 
beat out nearly as thin as paper, by passing through a 
rib and lodging in one of the vertebrse. These extraneous 



g^ ELEMENTS OF SURGERY. 

substances however do less mischief than in any other 
kind of wounds, because as they are in contact with 
dead parts, they occasion no irritation, and as these dead 
parts are themselves foreign matter and must be dis- 
charged by suppuration, the wound is not much delayed 
ia healing by their presence. 

TREATMENT OF GUNSHOT WOUNDS. 

The various phenomena of gunshot wounds, being of 
a nature not very readily explained by the older surgeons, 
induced some to believe that they were poisoned, others 
imaghied the ball to be intensely hot, and supposed the 
peculiarities of these accidents to depend on the burning 
of the sides of the wound. The essential difference, and 
the only difference between gunshot and other contused 
wounds, is found to consist in the death of those parts 
through which the ball has passed, and the necessity for 
the separation of these parts before union can be effected. 

It was formerly the custom to dilate all gunshot 
wounds, and much mischief has resulted from the prac- 
tice. There is nothing in the nature of this kind of ac- 
cident that calls for dilatation in every case, nor is there 
any tiling forbidding the practice when particular cir- 
cumstances render it proper. If an artery be opened by 
a gunshot wound, and the enlargement of the wound by 
a knife will enable the surgeon to tie it up, he ought 
surely to perform the operation. In general it is unne- 
cessary to dilate a gunshot wound for the purpose of ex- 
tracting a bullet or other extraneous matter, because sup- 
puration must come on, and this process will generally 
effect the object. If extraneous matter is perceived, and 
can easily be removed, it may be done; but it is wrong 
to enlarge the wound or take much pains to effect, what 
will be more readily done at a future period. The same 
reasons which would induce a surgeon to dilate a punc- 



ELEMENTS OF SURGERY. 63 

tured wound, or any other kind of wound, should lead 
him to dilate a gunshot wound, these reasons have been 
already stated. 

When a ball can be found without difficulty, it is 
right to extract it by means of forceps, the course of a 
ball however is so extremely irregular, that we are not 
always able to find it. The glancing of balls is in many 
cases very surprising. Mr. Hunter has seen a bullet 
enter the skin over the tibia, and pass round the leg un- 
der the skin without injuring either the bone or the skin. 
Wiseman relates cases where balls have passed through 
joints without occasioning an injury to the bones or car- 
tilages. When the velocity of a ball is nearly spent, a 
slight resistance will turn it from its course; balls have 
been known to pass round half the skull between the 
cranium and scalp, and then pass out opposite the part 
at which it entered. In the same way they have passed 
round the thorax, and glancing from a rib and kept from 
passing out by the resistance of the skin. Mistakes have 
been occasioned by these irregularities, and bullets are 
said to have passed through the head and chest in many 
cases where no such thing has happened. The posture 
of the body when the wound was received, should be 
attended to when the course of a bullet is searched for ; 
a ball has entered the arm antl been found on the oppo- 
site side of the body, owing to the horizontal posture of 
the limb when wounded. 

In many instances balls pass immediately under tlie 
skin to a considerable distance, their course being mark- 
ed by a red line extending from the spot where it enter- 
ed, to that at which it escaped or is lodged. Where 
bullets are lodged superficially under the skin^ they may 
with great safety and 'propriety he cut out, and no mis- 
chief in general arise from this new opening. The 
propriety however of extracting balls thus situated has 



g^, ELEMENTS OF SURGERY. 

been questioned, and Mr. Hunter remarks, that if the 
skin over it be quite sound, he would " in that case ad- 
vise letting it alone, until the wound made by the en- 
trance of the ball had inflamed and was suppurating.'' 
His reasons for this direction are, " 1st. We find that 
most wounds get well when the ball is left in (except- 
ing it has done other mischief than simply passing 
through the soft parts) and that very little inflammation 
attends the wound where the ball lodges, only that 
where it enters, the inflammation not arising so much 
from the injury done by the ball, as from the parts being 
there exposed to the suppurative inflammation, if it is 
immediately removed. There is always a greater chance 
of a slough where the ball enters than where it rests, 
arising from the greater velocity of the ball, for beyond 
where the slough is, the parts unite by the first in- 
tention.'' 

^^2dly. In those cases where the ball passes through 
and through, we have two inflammations, one at each 
orifice, instead of the one at the entrance, or a continued 
inflammation through and through, if the ball has pass- 
ed with great velocity. Where the ball makes its exit, 
the inflammation passes further along the passage ol the 
ball, than when the wound has been healed up to the 
ball and then cut out afterwards, so that by opening im- 
mediately the irritation will be extended further, and of 
course the disposition for healing will be prevented. If 
this is the case, I think that two wounds should not be 
made at the same time, and what convinces me more of 
it is, that I have seen cases where the balls were not 
found at first, nor even till after the patients had got 
well of their wounds, and these balls were found very 
near the skin. They gave no trouble (or else they would 
have been found sooner) no inflammation came upon the 
parts, and afterwards they were extracted and did 
well." 



ELEMENTS OF SURGERY. 65 

'^ Again I have seen cases where the balls were found 
at first, and cut out immediately, which were similar to 
balls passing through and through : the same inflamma- 
tion came on the cut wounds that came on the wounds 
made by the entrance of the ball.'' 

On these remarks of Mr. Hunter, I beg leave to offer 
a few observations. A musket or pistol bullet will doubt- 
less in a majority of cases excite no unpleasant symp- 
toms, the parts will heal around it forming a sac ; but 
a bullet is always extraneous matter, and in a majority of 
cases carries with it other extraneous matter, cloth, linen, 
&c. which cannot fail to irritate the flesh in which they 
lodge; they act like setons in keeping up suppuration 
and preventing the union of the wound, effects which I 
have witnessed in several cases ; in one a very large ab- 
scess was formed on the back in consequence of a ball 
being suffered to remain nineteen days under the skin 
near the angle of the scapula. 

It is with great diffidence that I would venture to op- 
pose on a practical point, the authority of Mr. Hunter, 
but I cannot but believe it right whenever a ball presents 
itself in such a situation, as that it may be extracted with 
facility, and without risque of injuring any important 
part to remove it immediately, without waiting for sup- 
puration. The wound made by the knife may common- 
ly be healed by the first intention. The ball should be 
suffered to remain whenever it is deeply buried in the 
flesh. All other extraneous matter if easily removed 
should be extracted, but probing or other violence must 
be avoided ; the finger is to be preferred to all instru- 
ments in examining gunshot wounds. 

Sometimes bullets are lodged in the substance of the 
bones, all violent attempts to remove them are wrong ; the 
bone will exfoliate, and when suppuration takes place, 
the ball will be discharged. In some cases balls and other 

VOL. I. 10 



65 " ELEMENTS OF SURGERY. 

extraneous matter have remained in bones or in the soft 
parts during life, without exciting any unpleasant eff'ects, 
but sometimes they produce suppuration and are evacu- 
ated long after the wound has healed. A very remarka- 
ble instance of this kind, I shall quote from a letter with 
which I have been favoured by Mr. John Randolph, of 
lloanoke. Major S. was wounded in the arm at the bat- 
tle of Germantown : " the wound healed, but was occa- 
sionally painful and once or twice suppurated and healed 
again. At length, about twenty-five years after the injury 
had been received, the wound broke out for the last time, 
"when a small shred of woollen cloth, recognized by the 
patient as a portion of his coat, and another of linen, were 
discharged ; they seemed to have undergone no sensible 
alteration except saturation with the pus and sanies in 
which they were immersed." 

For the removal of musket balls, a variety of forceps 
have been constructed. A prize was given by the French 
Academy of Surgery to Mr. Percy for one which appears 
to answer extremely well. The instrument is represented 
in PL II. When a leaden ball is lodged in a bone, the 
screw which is contained in one of the handles may be 
easily made to enter it, and it can be extracted. This 
screw, however, is so seldom needed, that it is omitted in 
the bullet forceps used in the service of the United States. 

When an extremity has been shattered by a cannon 
ball, the extent of injury is in some instances so great as 
to require the immediate removal of the member, we shall 
mention the circumstances which call for this operation, 
when we treat of amputation. 

The best local application to a gunshot wound, is a soft 
poultice of bread and milk, or linseed, to be continued 
until the sloughs separate and suppuration is established. 
The treatment is to be similar to that of any other con- 
tused wound. The state of the constitution must be very 
carefully attended to. 



/'rn-j's /ml/^'/y Foraps 



I'l. 'J. 




ELEMENTS OP SURGERY. 6*»' 

When there is reason to apprehend that the parietes of 
any considerable blood-vessel has been killed by the ball, 
great care should be taken to attend to the separation of 
the sloughs, as serious and fatal hemorrhages have some- 
times resulted from neglecting this caution. 

When bones are injured, the soft parts in some cases 
heal up, and when the injured bone exfoliates, an abscess 
fm'ms. and the wound must be opened afresh. 



68 ELEMENTS OF SURGERV. 

CHAPTER XII. 

Of PoisoTied Wounds. 

Poisoned wounds are those attended with an intro- 
duction of certain healthy or morbid secretions of animals 
or vegetables capable of producing disease and death ; as 
the bite of a venomous reptile, of a rabid animal, or a 
wound with a poisoned arrow.* 

The sting of a bee, wasp, or hornet, the bite of a mus- 
quitoe, and certain other insects, although in degree very 
moderate, probably partake somewhat of the nature of 
poisoned wounds. It is unnecessary to say much of these. 
Although frequent in their occurrence, they are generally 
not so severe as to require medical aid. The sting of a 
bee, wasp or hornet, is always extremely painful, and is 
followed by inflammation, and sometimes by great tume- 
faction. Cold applications affortl great relief. Cold 
water or lead water may be used. When the patient has 
been attacked by a swarm of these insects, and his head 
and face (which generally in these cases suffer) are much 
swelled, bleeding and a purge become necessary. 

The bite of the musquitoe is in some parts of our coun- 
try extremely annoying, and excites considerable inflam- 
mation, attended with intolerable itching. In some rare 
instances, owing probably to peculiarity of constitution, 
gangrene has resulted from the bite of this insect. I once 
knew a case of it fatal in a lady of this city, whose health 
previously was very good. Camphorated spirits, brandy, 

• With respect to the manner in which poisons act in producing death, the 
reader is referred to Fontana; the late experiments ofTVfr. Magendie upon the 
« upas tieute," and also to the interesting experiments of my friend Mr. Brodie^ 
related in the Transactions of the Royal Society of LondoHv 



ELEMENTS OF SURGERY. 5g 

or vinegar, generally afford relief of the itching, and the 
inflammation in a few hours commonly subsides. Violent 
mbbing to allay the itching should be avoided. 

The rattlesnake, one of the most venomous reptiles in 
the world, is found in many parts of our country.* Like 
the cobra de capello in India, the bite proves speedily 
fatal, and we have very few histories of the effects of the 
poison. 

Professor Barton, whose indefatigable labours have 
thrown light on every branch of physical science, has 
published in the 3d vol. of American Philosophical 
Transactions, a valuable paper on the subject, to which 
the reader is referred for much interesting information. 

It appears from Dr. Barton's remarks, and from the 
observation of others, that " in the season of supervening 
languor and torpidity, the rattlesnake in particular bites 
with seeming reluctance, and without any or with but 
little ill consequence arising from the wound;" and 
"even in those seasons when the sun powerfully exerts 
its influence, at wliich times these animals are best quali- 
fied to strike and to injure, individuals of the species 
must be often found, the cavities of whose venomous 
fangs are entirely or nearly destitute of their active poi- 
son, from the introduction of which into their body those 
alarming symptoms which characterise the successful 
bite of this animal arise." Three chickens were bit by a 
rattlesnake kept in a cage, on three successive days. 
The first died in a few hours ; the second survived much 
longer than the first; the third swelled much, but never- 
theless recovered. On the fourth day several chickens 
were bitten, without receiving any injury. These cir- 
cumstances are mentioned by Dr. Barton, to shew that 
the various supposed vegetable specifics for the bite of 

• There are several species of a-otalus. I refer to the " crotalus homdu%" 
which is the most common species. 



yO ELEMENTS OF SURGERY. 

the rattlesnake owe their reputation to their having been 
used in cases where no bad effects would have resulted. 

As the poison of the rattlesnake « exerts its principal 
effects on the sanguiferous system," immediate care 
should be taken to cut off the circulation of blood through 
the wounded part. When the poison enters a considera- 
ble vein or artery, death in general speedily ensues ; 
often in the space of two minutes. Of this Dr. Barton 
has been assured from a variety of sources, although he 
is unwilling to believe the wound necessarily mortal. 
The wound being generally in the lower extremities, he 
recommends the immediate application of a tight ligature 
round the limb, to prevent the access of the poison to the 
circulation either by the veins or absorbents. " As poi- 
sons of various kinds are liable to be detained for some 
time in the glandular appendages of the absorbent system, 
it would perhaps be of use to scarify these parts, and ap- 
ply a blister to them, in order to promote the discharge 
of the poison." When the glands in the groin swell, as 
they speedily do after a bite in the foot, the scarifications 
are to be made there, and a prompt vesication excited by 
the bark of the Daphne Gnidium. 

I think there can be no doubt of the propriety of ex- 
tirpating immediately the wounded part, as this will ef- 
fectually cut off all communication with the circulating 
blood. The use of the numerous vegetable remedies 
which have been employed in these cases appears en- 
titled to but little attention. The internal administration 
of volatile alkali has been very often employed, but pro- 
bably its virtues are much overrated. 

"When the poison of the rattlesnake has actually 
been introduced into the general mass of blood, it begins 
to exert its most alarming and characteristic effects. A 
considerable degree of nausea is a very common symp- 
tom. We now discover an evident alteration in the pulse ; 
it becomes full, strong and greatly agitated 5 the whole 



ELEMENTS OF SURGERY. yi 

body begins to swell ; the eyes become so entirely suf- 
fused; that it is difficult to discover the smallest portion 
of the adnata that is not painted with blood. In many 
instances there is an hemorrhage from the eyes, and like- 
wise from the nose and ears ; and so great is tlie change 
induced in the mass of blood, that large quantities of it 
are sometimes thrown out on tlie surface of the body in 
form of sweat. The teeth vaccillate in their sockets, 
whilst the pains and groans of the unhappy sufferer too 
plainly inform us that the extinction of life is near at 
hand." ' 

*^ In this stage of its action, and even before it has in- 
duced the most alarming of the symptoms which I have 
mentioned, the powers of medicine can do little to check 
the rapid and violent progress of this poison. The em- 
ployment of the ligature, the use of the blister, and of the 
other modes of treatment which I recommended in the 
local stage, it is obvious to remark, will be of little, if any 
benefit here." (Barton.) 

Perhaps the same remarks will be found applicable in 
cases of bites from the other venomous serpents of Ame- 
rica, but my own experience does not warrant me in of- 
fering any thing on this subject. 

The bite of rabid animals is in all instances to be treat- 
ed by extirpation with the knife, and when any doubt 
exists as to the removal of all the injured parts, caustic 
should be applied, so as to render their separation abso- 
lutely certain. This is to be done even if months have 
elapsed after the healing of the wound, upon the prin- 
ciple of leaving nothing undone which can possibly be 
instrumental in preventing so terrible a disease as hydro- 
pliobia. 

Inoculation with morbid poisons is foreign from our pre- 
sent subject, and with respect to poisoned arrows, and the 
effects of the " upas tieute," I refer to the experiments 
of Mr. Magendie. 



73 ELEMENTS OF SURGERY. 

CHAPTER Xm. 

Of Particular Wounds. 

The Scalp is liable to all the varieties of incised and 
contused wounds ; they are often accompanied with in- 
juries of the brain. A mere wound of the scalp is to be 
treated as a similar wound in any other part. The hair 
is to be carefully shaved^, the extraneous mattef removed, 
the divided parts replaced in contact, and secured so by 
adhesive plaster, or if necessary, by stitches. The vessels 
of the scalp seldom bleed so as to require the use of a 
ligature. When a large artery, however, is opened, as 
the occipital, or one of the principal branches of the tem- 
poral, it must be taken up : the needle is found more 
convenient for tying up arteries in the scalp than the te- 
naculum. 

Punctured wounds of the scalp often occasion violent 
inflammations, in consequence of the parts underneath the 
tendon of the occipito frontalis muscle being injured. The 
usual remedies for inflammation relieve it. 

In extensive lacerated wounds great portions of the 
scalp are separated, leaving the pericranium, and in 
some places, the bone bare. It was the practice for- 
merly to remove all such detached portions by the knife, 
than which nothing can be more absurd. The doctrines 
of adhesion, taught by Mr. Hunter, have in this, as in 
many other important instances, triumphed over the bar- 
barisms of former ages, and demonstrated the propriety 
of preserving, in every instance, the separated scalp. 
The parts are to be cleansed and placed in contact, and 
they will generally unite by adhesive inflammation ; and 
if suppuratioH should even take place, granulations will 



ELEMENTS OF SURGERY. ^3 

form, and the union, though more tardy, will be equally 
certain. I have seen nearly one half the scalp torn off, 
and covered with dirt and splinters of wood, which, 
when carefully cleansed and replaced, united in. a few 
days with very little suppuration. 

W'OUNDS OF THE FACE. 

The face is liable to the various kinds of wounds 
which have been described, and they require no particu- 
lar mode of treatment from their situation, except that it 
is of peculiar importance to make the cicatrix as small 
and as smooth as possible, to prevent deformity. Sutures 
are of course to be avoided, and sticking plaster to be 
used. In Avounds of the eyelid, however, it sometimes 
happens that a stitch or two is necessary. In these 
cases care must be taken not to pass the ligature through 
the adnata, as in that case great irritation will be the 
consequence. 

In the treatment of wounds of the eye, the great 
objects are to extract all foreign matter and to make use 
of very powerful measures to prevent and relieve the 
inflammation of this important organ. The various reme- 
dies for inflammation of the eye will be detailed when 
we speak of ophthalmia. 

Where the lip is cut through, if the wound be small, 
s,ticking plaster will be found suflicient to keep its sides 
together; but if it be half an inch or more in extent, the 
interrupted or twisted suture will be necessary. When 
the tongue is cut, stitches must be used. In childre^i 
we often find the tongue wounded by the teeth in conse- 
quence of falls. A hook is in these cases generally ne- 
cessary to keep the tongue sufficiently forward to enable 
the surgeon to perform the operation. A piece of soft 
wood should be placed between the teeth to prevent the 
< iiild from biting the surgeon. Tn the course of six or 

VOL. T. a 



y-l) ELEMEXTS OF SURGERY. 

eight (lays the stitches may be removed. During the 
cure the child should not be allowed to chew any solid 
food, but must be nourished entirely on fluids. 

When the ears are wounded, if a portion is nearly 
detached, stitches are necessary; but in many cases the 
adhesive plaster is found equally effectual, and should 
therefore be preferred. 

Contused wounds of the face are to be poulticed until 
suppuration commences and granulations form, and then 
the adhesive strips are to be applied. 

WOUNDS OF THE THROAT. 

From the important parts which are here situated, and 
from the magnitude of the blood-vessels generally divi- 
ded, wounds of the throat are among the most dangerous 
to which the surgeon is called. 

Superficial wounds of the throat require no particular 
treatment, but generally heal as readily as wounds of 
other parts. Sometimes, however, the trachea is divided, 
together with large veins and arteries, even the oesopha- 
gus, and carotid artery, without immediate death. — 
Whenever the carotid artery is opened freely by a sharp 
instrument, fatal hemorrhage very promptly takes place : 
but Mr. Abernethy has recorded an instance in which a 
lacerated m ound of this vessel was occasioned by the 
horn of a cow, and the bleeding was not attended with 
fatal consequences. Wounds of the throat most frequent- 
ly occur in attempts to commit suicide ; and as the in- 
strument is commonly a razor or very sharp knife the 
hemorrhage is profuse, and is always the first thin*^ de- 
manding attention. 

Every bleeding vessel should be immediately secured 
by a ligature. The external jugular veins are generally 
opened, and these, as well as the divided arteries, are 
to be tied. The carotid itself should be tied up, if the 



ELEMENTS OF SUBGERY. ^5 

surgeon arrive in time to effect it. Mr. Abernethy^ in the 
instance just noticed, secured this vessel by a ligature, 
and his patient survived thirty hours. He remarks that, 
" should it become necessary at any time to tie the carotid 
artery, it may be done without much difficulty or danger, 
even without an accurate dissection of the part. If the 
incision be made on that side of the artery which is next 
the trachea where no important parts can be injured as 
was done in the present instance, the finger can then bB 
passed behind the artery so as to compress it. The ves- 
sel being sufficiently bulky and firm to make its form and 
outline distinctly perceptible, a needle may then be pass- 
ed behind the artery as near as possible to that edge of 
it which is next to the internal jugular vein; there can 
])e little risk of wounding that vessel, or of including in 
the ligature the eighth pair of nerves which lies between 
them. In attempting to secure the carotid artery, I passed 
behind it in the manner described, a blunt hook with au 
eye in the point, and having previously introduced a 
ligature into it, I drew back the instrument and thus en- 
closed the artery. 

In an incised wound of the carotid artery a very dif- 
ferent and much more expeditious method would be ne- 
cessary. The operation has hitherto never been done, 
but a case may possibly occur in which the surgeon may 
be present. In such a case I can see no impropriety iu 
passing a sharp armed needle round the carotid without 
attending to nerves or any thing else. This ligature 
being 2;iven to an assistant, a second should be instantly 
passed in the same manner round the upper orifice. The 
hemorrhagy could now be restrained until the wounded 
vessel could be drawn out separately with a tenaculum 
or forceps, and both its cut extremities tied; after which 
the first ligatures which had been used as tourniquets 
should be removed. 



^(5 ELfcMEKTS OF SURC.EKY. 

The hemorrhage being stopped, the sides of the wound 
are to be brought together, if possible without the use of 
stitches. Where the trachea is only partially divided, 
adhesive plaster may always be used ; if it be cut com- 
pletely through, it is generally recommended to make 
use of the interrupted suture; but in some cases the 
stitches occasion great irritation, and are ulcerated out 
before the union of the wound, leaving it in the same 
state in which it had been before the use of tbe needle. 
The interrupted suture is, however to be used, whenever 
the wound of the trachea cannot be approximated without 
it; and whenever it is used, great care must be taken to 
pass the needle merely through the cellular texture sur- 
rounding the trachea, as the thread, if allowed to pass 
through the inner membrane of this canal, would add 
greatly to the irritation. In addition to this the head 
must be bent forward so as to favour the approximation 
of the sides of the wound, and it is to be kept so by 
bolsters and bandages: care, however, is necessary in 
all such cases, to guard against a collection of blood or 
mucus in the trachea, as death has been occasioned by a 
neglect of this caution. Whenever blood flows in this 
way into the trachea, and is not readily coughed up, the 
wound should be opened, in order that it may be dis- 
charged. 

Where the oesophagus is also opened, it is difficult, 
unless the external wound be very extensive, to make 
any application to it. Desault in these cases recommends 
the introduction of an elastic catheter of large size, 
through which the necessary food may be injected into 
the stomach, and this practice has been found extremely 
useful in a number of cases. It should be sulFered to 
remain during the cure, and will produce no ill effect, 
but on the contrary will preclude all that irritation which 



ELEMENTS OF SURGERY. r^ 

would arise from the action of the muscles in attempts 
to swallow. The tube may be passed either through the 
mouth or nostril, according to circumstances. The oeso- 
phagus is sometimes punctured by a sword, bayonet, or 
knife, without any wound of the trachea. In this case, 
if tiie blood-vessels escape, the wound generally heals 
readily. 

The great contraction of the parts in large wounds of 
the throat produces a very unpleasant appearance of loss 
of substance. I have seen sevei*al cases in which scarcely 
any soft parts intervened between the lower jaw and the 
sternum; the throat seemed to have sunk into the thorax, 
or to have been cut away and removed. In the Medical 
Commentaries a case is related by Mr. Stark, in which 
this retraction was so great that "between the clavicles 
and OS hyoides there was only one continued gash, which 
looked as if the windpipe and gullet had been cut out en- 
tirely." In these cases great attention must be paid to 
keeping the head close to the top of the chest. 

Longitudinal wounds of the trachea heal in general 
without difficulty by the application of sticking plaster. • 

It has been doubted by some surgeons, " whether the 
oesophagus can ever be wounded without destroying at 
the same time the large blood-vessels and nerves, so that 
the patient must instantly die.''* There is no doubt that 
the escape of food and liquids through the external open- 
ing has been considered a proof of a wound in the oeso- 
phagus in cases where the knife or razor has passed 
above the os hyoides and entered the mouth ; but it is 
equally certain, that in many cases the trachea has been 
completely divided, and the oesophagus not merely open- 
ed, but cut nearly asunder, the wound extending almost 
to the cervical vertebrje, without injuring the carotid ar- 

• Latta, Vol. Ilf. p. 13i 



78 KLEl^lEMS OF SUUGERY. 

teries. Mr. Stark's case was of this kind. " The pha- 
rynx was cut through, except about a finger's breadth of 
the back part.'' I have seen a case nearly similar, in 
which the trachea was cut completely asunder, and the 
cBsophagus opened^ without any wound of the carotid ar- 
teries. 



ELEMENTS OF SURGERY. 'J'9 

CHAPTER XIV. 

Of Wounds penetrating Cavities. 

The thorax and abdomen are sometimes opened, and 
very dangerous consequences often result, especially if 
any of the viscera contained in these cavities be injured. 

WOUNDS OF THE THORAX. 

When the thorax is wounded to a depth sufficient to 
open the cavity of the pleura, the admission of air pro- 
duces an immediate collapse of the lung, and breathing 
is performed with great difficulty. The lung so completely 
fills the cavity of the chest that it is generally injured in 
gunshot wounds and in stabs with a dirk or sword. When 
this is the case blood is coughed up. If a considerable 
blood-vessel is opened either in the parietes of the thorax 
or in the lung, blood collects in the cavity of the chest, 
produces great oppression, and increases the difficulty of 
breathing. 

When the wound is a simple incision through the pa- 
rietes of the thorax, it should be dressed with adhesive 
plaster, its sides being accurately brought in contact. A 
compress should be next applied, and over this a roller 
moderately tight round the chest. The patient should be 
kept at rest, and observe a strict antiphlogistic regimen, 
and be bled to prevent the accession of inflammation. 
Treated in this way, incised wounds of the thorax very 
generally heal without difficulty. The great object of 
the surgeon in every such case is to effect as speedily as 
possible the union of the wound, because whenever the 
cavity of the thorax is opened, unless union by the first 
intention or by adhesive inflammation takes place, violent 



80 ELEMENTS OF SURGERV. 

inflammation comes on, frequently followed by fatal con- 
sequences. 

The practice of closing tlic external wound after a vio- 
lent effort to force out tlie air from the pleura, and in- 
deed all attempts to draw the air out from it, are unne- 
cessary; the wound may be closed without attending to 
the state of respiration, and the air left in the cavity of the 
chest will be absorbed without occasioning any ill effects. 

The great anxiety which has been shewn to evacuate 
the air, originated in an opinion that the air of the at- 
mosphere is a violent irritant, capable of exciting great 
inflammation: an opinion not at all founded in truth. In 
the year 1790, Dr. Physick injected air into one side of 
the thorax of a kitten, through a small puncture between 
the ribs. The wound healed by the first intention, and 
appeared to occasion very little inconvenience to the ani- 
mal. On the fourth day the kitten was killed, and not a 
vestige of inflammation was observable. Many cases 
have occurred in the human subject in which the cavity 
of the pleura has been filled with air in consequence of a 
wound, and the wound being speedily healed, no inflam- 
mation has resulted. I once saw an officer who had been 
wounded with a dirk ; the air entered and passed out of 
the wound freely during respiration ; this wound uni- 
ted by the first intention, and in a week he was com- 
pletely well, not having experienced a single symp- 
tom of thoracic inflammation.* 

It happens in many cases that the existence of pulmo- 
nary disease occasions adhesions between the pleura cos- 
talis and pleura pulmonalis, in such a manner as par- 
tially or even totally to obliterate the cavity of the pleura, 
When a wound is received in the chest under these cir- 

• It is remarkable that the French surgeons, and indeed many others, retain 
this strange notion of the irritating nature of atmosplicric air. The principal 
case in which it irritates, is when it occasions fermentation in the cavity of an 
abscess. 



ELEMENTS OF StJRGERY. g^ 

cumstances the danger of inflammation is much dimi- 
nished. 

Whenever inflammation comes on in consequence of a 
wound in the ehest, bleedings, copious and i*fcpeated, must 
be employed ; all the remedies for inflammation are to be 
vigorously administered, and in general they are suc- 
cessful. 

When the lung is wounded, the patient will cough up 
blood, and if a large vessel be opened, (and a great num- 
ber exist in the thorax of the largest size) fatal hemorr- 
hagy will in general quickly ensue, and yet the heart itself 
has in some cases been wounded, and also the aorta, 
without immediate death. 

There is reason to believe that the heart has often, 
been slightly wounded without fatal consequences, and 
Dr. Babington has related a very interesting case in which 
the heart was wounded by a bayonet without immediate 
death. The patient was a marine on board a ship of war, 
and acting as sentinel at the gangway, fell through to the 
lower deck, and caught upon the point of his bayonet. 
" It entered his side a little below the false ribs, nearly 
in a perpendicular direction, and had penetrated to its 
hilt, having sustained the weight of his whole body. The 
poor man at the time did not feel himself much wounded. 
He drew out the bayonet without assistance, rose, lifted 
his musket, said he was not much hurt, and, as if he 
thought himself still fit to continue sentinel, walked eight 
or ten steps, then dropt down suddenly in a faint. On 
being laid in a horizontal posture he soon recovered, and 
was brought to the hospital (at Haslar) about 7 o'clock in 
the evening, which was about two hours after the accident. 
He then made very little complaint of pain, but lay con- 
stantly on the side opposite to that which was wounded, 
was inclined to sleep, and when asked a question, spoke 

VOL. I. 13 



8g ELEMENTS OF SURGERY. 

slowly, as if in great distress. The wound was in the left 
side, about two inches above the hip bone, and penetrated 
into the cavity of the belly, but neither its direction nor 
depth could be ascertained. He did not seem to have bled 
much, but was very faint, his body cold, and the pulse 
scarcely perceptible. The circulation was so languid, 
that, though a vein was opened in both arms, no blood 
could be obtained." He soon after his admission into 
the hospital began to breathe with difficulty, (which at 
first he had not done.) A great sense of weight was ex- 
perienced about the chest. He felt some pain in the 
breast. A swelling next took place, proceeding from 
the breast all over the body. A little after two o'clock in 
the morning, {nine hours after the wound was receivedj) 
a sudden strangulation in the throat put a period to his 
life. 

Upon dissection it was found that the bayonet had 
penetrated through the integuments, the abdominal mus- 
cles and peritoneum, had pierced the colon, the stomach, 
the left lobe of the liver, the diaphragm, and entered the 
thorax at its centre. Immediately within the breast the 
pericardium had presented and yielded the instrument a 
ready passage to the heart. TAe right ventricle there 
received it. The point was thrust in at the lower part 
of the ventricle, and had forced its way out near the 
valve. From the heart, again passing the pericardium, 
it pierced through both the upper and middle lobes of 
the lungs, but even these were insufficient to detain it. 
It forced a passage on the right side near the sternum, 
between the cartilages of the second and third ribs, and 
had sheathed its point beneath the pectoral muscle. 
That muscle was slightly wounded, but the integuments 
above it were unhurt. A little bloody serum was found 
in the cavity of the belly, but scarcely any pure blood. 
The pericardium contained a little blood. The ri-^ht 



ELEMENTS OF SURGERY. §3 

side of the breast coutained above two quarts of blood, 
partly in a fluid and partly in a coagulated state. 

I have quoted this abridgment of the case, because, 
although so terrible a wound as that here described must 
be considered necessarily fatal, yet, during the time the 
patient lived, a simple puncture of one of the cavities of 
the heart might have united. 

Mr. Pelletan, has lately published a case in which the 
aorta was punctured by a small sword in a duel. The 
weapon entered above the right pap, and from his bent 
posture, passed through his body and out of the left side 
near the lumbar region. The young man declared the 
wounds to have been made by the same thrust, (which 
was doubted at first from the strange course of the sword) 
and said he had himself pulled it out. The most dan- 
gerous consequences were expected, but many days 
passed without any. He complained of pain in the 
lumbar region, but the warm bath, two bleedings, and a 
low diet relieved this, and he lived two months after the 
accident, at which time he expired in great pain, a tu- 
mour having formed opposite to the eighth dorsal verte- 
bra. Upon dissection the right side of the chest was 
found filled with blood coagulated in different degrees. 
This blood led to an opening as large as a writing quills 
w ith which the aorta was pierced, above the crura of the 
diaphragm. These crura and the surrounding cellular 
texture were injected with extravasated blood. No viscus 
of the abdomen or thorax had any mark of injury (the 
sword having probably passed behind them) and there 
was no reason to expect a priori a wound of the aorta.* 

Hemorrhage from wounds of the chest cannot be com- 
manded by ligature, unless it proceeds from an intercostal 

• Chiniqve Chirurgicalc, torn. i. p. 92. 

A case of ruptured aorta is described by Mr. Linn, ji\n. in which the patient 
survived two weeks. Medical lieinrda. 



g4j ELEMENTS OF SURGERY. 

artery. The intercostal arteries are sometimes wound- 
ed, and although not very large, bleed freely. It has 
been proposed to secure the vessel by passing a ligature 
round the rib, and tying a piece of lint upon it. As 
this operation, however, would leave a foreign substance 
in the cavity of the thorax (a portion of the ligature) 
much inflammation would result from it; and although I 
have never seen such a case, I cannot but express my 
opinion that a safer measure would be to make a free ex- 
ternal incision, and secure the vessel in the usual way, 
pulling it out with a tenaculum which could with com- 
mon dexterity be performed. 

Wounds of the larger vessels of the lungs generally 
terminate the existence of tlie patient in a few minutes. 
If the lungs be wounded, witliout injury to any of the 
great vessels, abscesses frequently form in the chest, at- 
tended with hectic fever, night sweats, great exhaustion, 
diarrhcea, and eventually death. In some cases, how- 
ever, bullets and also small swords, have passed through 
the chest, and still the patients have recovered. 

Mr. Hunter remarks, " it is pretty well known that 
wounds of the lungs (abstracted from other mischief) are 
not mortal. I have seen several cases where the patient 
has got well after being shot quite through the body and 
lungs, while from a very small wound made by a sword 
or bayonet into the lungs the patients have died, from 
which I should readily suppose that a wouwl iu the 
lungs from a ball would in general do better than a 
wound in the same part with a pointed instrument, and 
this difference in effects would in many cases appear to 
arise from the difference in the quantity of blood extra- 
vasated, because the bleeding from a ball is very incon- 
siderable in comparison with that from a cut, and there 
is therefore a less chance of extravasated blood, either in 



ELEMENTS OF SURGERY. gg 

tlie cavity of the thorax or the cells of the lungs. Another 
circumstance that favours the gunshot wounds in these 
parts is, that they seldom heal up externally by the first 
intention, on account of the slough, especially at the 
wound made by the entrance of the ball, so that the 
external wound remains open a considerable time, by 
which means any extravasated matter may escape ; but 
even this has often its disadvantages, for by keeping 
open the external wound which leads into the cavity, we 
give a chance to produce the suppurative inflammation 
through the whole surface of that cavity, which would 
most probably prove fatal." 

When the quantity of blood poured out into the cavity 
of the pleura is small, if it do not readily escape at the 
external wound, the absorbents take it up ; but if the 
wounded lung continue to bleed into the cavity of the 
pleura, symptoms of an alarming kind are produced- 
Great prostration of strength, which proceeds from the 
nature of the parts wounded, and perhaps a fainting from 
the quantity of blood lost to the circulation. A great 
heaviness will be felt in the breast, and considerable 
difficulty of breathing. The causes of this difficult res- 
piration will be the pain which the patient will have in 
expanding the lungs in inspiration; the injury of some of 
those muscles wliich move the ribs ; and also the dimi- 
nution of the capacity of the thorax, from the effusion of 
blood into the cavity of the pleura which prevents the 
complete expansion of the lungs. 

The patient will not be able to lie down, but must sit 
upright, because this posture throws the weight of the 
eflused blood upon the diaphragm and forcing this down- 
wards, somewhat enlarges the thorax. Wherever a 
large extravasation of blood into the cavity of the pleura 
exists, an oj)ening for its evacuation must be made, and 
this should be done if possible before it coagulates, ia 



86 ELEMENTS OF SUllGERY. 

order that it may the more readily escape through a 
small wound. 

In some cases it may be convenient to enlarge the 
original wound, but it is often necessary to make a new 
opening, which may be done with a scalpel, just above 
the upper edge of any of the ribs. If a small opening 
suflice to evacuate all the blood, it will be more apt to 
heal by the first intention, but if the blood be found 
coagulated, a larger aperture will be necessary. When 
the contents are evacuated the wound must be accurately 
closed with adhesive plaster. 

Sabatier takes notice that many writers recommend 
this operation, but that very few have performed it. He 
relates, however, one case in which it became necessary 
from a bleeding from the internal mammary artery after 
a gunshot wound. Mr. Saucerotte performed it, and his 
patient recovered.* 

The treatment of gunshot wounds penetrating the tho- 
rax, is to be extremely simple ; superficial dressings are 
to be applied, a soft poultice enclosed in a bag of gauze 
or muslin, or a pledgit of linen rag spread with simple 
cerate may be used. Great care is necessary to prevent 
the dressing from being drawn into the chest during inspi- 
ration, as much irritation would be the consequence of 
any foreign substance being introduced into the cavity of 
the chest. 

Gunshot wounds through the chest, when the sloughs 
separate, leave very considerable openings into the cavity 
of the pleura, and although it is a fact that these wounds 
are less generally fatal than stabs wit'li sharp instruments, 
from their bleeding less freely, yet they are much more 
complicated, and often attended with fractures of the ribs, 
and with extraneous matter in the thorax, as the clothins 
of the patient and the ball. They are followed by tedious 

* JMedicine Ot>eratolre. 



ELEMENTS OF SURGERY. gy 

exfoliations of the ribs ; by long continued suppurations 
and hectic fever, which however are not always fatal. In 
some instances the suppuration takes place from the 
whole cavity of the pleura, and immense quantities of pus 
are discharged. In some the lung gi*adually vs^astes 
away, and nothing remains of it but a hard diminutive 
tubercle at its root. 

"When a man is shot through the lungs, if death be 
very near, it must be from suffocation, and you will find 
him with a bloody foam at his mouth, his face pale at the 
clieeks, and livid round the lips and eyes, heaving the 
breast w itli intolerable anguish, tossing from side to side 
in bed, the bloody foam increasing, the breathing becom- 
ing more difficult, and the blood and air rattling in the 
throat ; then tlie pulse flutters, and the extremities con- 
tinually grow colder, till struggling in something like a 
convulsion he expires/*' John Bell. 

In this manner soldiers frequently perish on the field 
of battle, their cases admitting of no relief. But many 
cases, as we have already stated, do admit of relief, and 
as the primary danger depends on suffocation from the 
air cells of the lungs being filled with blood, the remedy 
mu.st be an immediate evacuation of blood by venaesec- 
tion, and this is to be carried to a greater length than in 
almost any other accident or disease, first w ith a view to 
unload the lungs and prevent suffocation, anS afterwards 
to prevent and cure the succeeding inflammation. The 
French surgeons have been famous for the quantities of 
blood which they direct to be drawn in such cases. 
They have been censiued for it, but I believe with Mr. 
John Bell, that it is hardly possible to carry the practice 
too far. Sabatier relates a successful case in which the 
patient was bled twenty-six times, and I have myself 
known a young man to lose one hundred and eighty 
ounces of blood in twelve days, in consequence of a gun- 



gg ELEMENTS OP SURGERV. 

sliot wound in the chest. He recovered rapidly, although 
a very large opening had been made by a load of small 
shot. 

In some cases emphysema occurs from wounds of the 
lungs. It commonly happens from the wound being of 
small size, and not entering in a direct line. " It is less 
frequent in large wounds with a knife or broad sword, 
because there the air has an open and unimpeded issue ;" 
and " more frequent in deep stabs with the bayonet or 
small sword ;" and " it is peculiarly frequent in gunshot 
wounds, because the orifice in the skin inflames and 
swells while the wound is wider within." 

Tliis singular affection consists in an escape of air from 
the lung into the cavity of the pleura, and from thence 
into the cellular texture over the wound, its escape being 
prevented by a closure of the external opening, the 
wound through the skin not corresponding with that in 
the pleura; sometimes it occurs without the lung being 
wounded from the air which entered the thorax by the 
external wound. In common it confines itself to the 
vicinity of the wound, but sometimes it extends very 
rapidly, swells the whole figure, closes the eyelids, ob- 
literates every appearance of the neck, which has the 
same diameter as the trunk. The extent to which the 
body swells in emphysema may be judged of from a case 
related by Mr. Littre in the Memoirs of the French 
Academy, in which the skin over the chest was distend- 
ed to the distance of eleven inches from the ribs. The 
palms of the hand and soles of the feet are the only parts 
which do not partake of the tumefaction. 

The treatment consists in making punctures through 
the skin with a lancet opposite to the wound in the tho- 
rax, by which the air may be allowed to escape. If small 
punctures through the skin be found ineffectual, a free 
incision is to be made into the thoraX; through the skin 



ELEMENTS OF SURGERY, §Q 

and muscles, which puts an immediate stop to the pro- 
gress of the complaint, care being taken to avoid the in- 
tercostal artery. 

In many instances it is not easy to ascertain whether 
the difficulty of respiration depends upon air or blood 
confined in the pleura. The incision is equally eflTectual 
in botli cases. It is not by compressing the lung of the 
wounded side that the oppression is occasioned, for this 
lung must be in a collapsed state from the moment when 
the air was admitted into the thorax, and of course res- 
piration is entirely performed by the opposite lung. The 
oppression proceeds from the pressure of air or blood 
upon this sound lung, its freedom of motion being there- 
by impeded. 

A protrusion of a portion of the lung through a wound 
of the chest is an accident which has sometimes occurred. 
Sabatier recites several cases, and in some the surgeons 
appear to have treated the patient very roughly, having 
cut off the protruded lung with a hot iron in one instance, 
and applied stiptic powders after cutting it off, in ano- 
ther.* Notwithstanding these harsh proceedings th« 
patients got well. 

The proper plan, if we are called before the pro- 
truded piece of lung is mortified, will be to replace it 
without delay; and if necessary the wound may be en- 
larged to facilitate its reduction. After this the usual 
dressings are to be applied. If mortification have taken 
place, Sabatier recommends the application of a ligature 
rouud the part to prevent hemorrhage, and the excision 
of the mortified portion, a practice which I think ought 
never to be followed, because, if the ligature be applied 
tight enough to command the hemorrhage, it will infalli- 
bly produce gangrene and slough off; now the mortified 

• Mddidne Op^ratoirr, torn. ii. p. 272. 

vol,. I. 1.3 



yO ELEMENTS OP SURGERY. 

part will as certainly separate without the ligature, and 
ought therefore in every case to be left. Until this sepa- 
ration happens, it will be safest to leave the mortified 
portion outside, because adhesions will form connecting 
the lung to the margin of the wound, so that when the 
separation of the slough takes place, the cavity of the 
thorax will not be exposed, whereas if a portion of mor- 
tified lung be returned into this cavity and there separate, 
it will undoubtedly occasion as great inflammation as 
other foreign matter, and render it necessary to keep 
open the external wound. 

When foreign substances, as fractured bone, pieces of 
cloth, &c. are lodged in the thorax, they must if practi- 
cable, be immediately removed. Pieces of the rib are 
frequently broken off* in such a manner as to project in- 
w ard and irritate the lungs. In this case a pair of forceps 
must be introduced, and the splinter separated. A mus- 
ket ball sometimes lodges in or about the thorax, and, in 
general, it is " irrecoverably lost ;" but the clothing car- 
ried in with it may commonly be found, and should be 
then carefully extracted, for every thing of this kind has a 
tendency, like the setons of the French surgeons, to keep 
up inflammation and suppuration. I was called to visit a 
carpenter wounded in the back by falling on a chisel ; 
the wound penetrated into the chest, and as the muscular 
flesh through which the chisel had passed bled freely, 
an old lady emptied her snuff box into the wound. At 
every inspiration some of the snuff entered into the tho- 
rax, and the consequence was a general suppuration 
from the cavity of the pleura, exposing the life of the pa- 
tient to great hazard. 

Care should be taken to extract every foreign body 
within our reach, and to prevent our dressings, &c. from 
being drawn into the chest. 



ELEMENTS OF SURGERY. gl 

CHAPTER XV. 

Wounds penetrating the Abdomen. 

In consequence of the great variety and importance of 
the viscera contained within the abdomen, wounds pene- 
trating this cavity must differ essentially in their nature 
and consequences according to the parts injured. 

In a wound through the parietes of the abdomen, in 
which none of these viscera are implicated, the great ob- 
ject of the surgeon is to produce a speedy union of the 
wound, in order to prevent the inflammation of the peri- 
toneum. There is no reason for believing that this in- 
flammation arises from the admission of air into the ca- 
vity,^ neither is the diminution of its temperature the 
cause, f as the application of ice in cases of hernia fre- 
quently reduces the heat of the abdomen much below that 
of the atmosphere, without any such effect, and peritoneal 
inflammation is as apt to occur in the hottest summer 
weather when the thermometer rises nearly to the heat of 
the blood, as in the depth of winter. The real cause of this 
inflammation in wounded cavities, it is by no means easy 
to ascertain, it is much easier to ascertain that none of the 
alleged causes can explain it. The fact is all we have 
to state. Whenever a large cavity, as the thorax, abdo- 
men, or a large joint, is cut open, unless the wound be 
promptly healed, violent inflammation occurs throughout 
the surface of that cavity. The imperfection of the cavity 

• The cavity of the abdomen is a plenum, every part of it occupied with 
something, and no space exists for the admission of air. Into the tliorax, when 
wounded, air finds a ready entrance, but not so in wounds of the abdomen. 

f This opinion has been maintained by Dr. James Cocke in his Inaugural 
Essay, published in this city in 1804. 



93 ELEMENTS OF SURGERY. 

appears to be the only circumstance necessary to the pro- 
duction of this inflammation, but how it effects it I am not 
prepared to say. 

If the wound be made by a sharp instrument, it is to 
be closed by the interrupted suture, care being taken to 
pass the needle from within outwards, about half an inch 
from the wound ; it is most readily effected by having a 
needle at each end of the ligature; none of the strings 
are to be tied until all the stitches are made.*- In this 
case I should not use leather ligatures. The various an- 
tiphlogistic remedies are to be used in order to prevent 
inflammation, and also to relieve it, if it supervene. 

It is always of extreme importance to ascertain whether 
any of the viscera of the abdomen be injured, because the 
danger of the case, and the remedies to be employed, de- 
pend greatly upon this circumstance. If any part of the 
bowels protrude, it should be examined carefully before 
it is replaced. If the wound be a small incision or a 
puncture, it is more difficult to ascertain the extent and 
nature of the mischief. Some information is to be gain- 
ed by examining the instrument with which the wound 
was inflicted, and by observing how much of it had en- 
tered, and in what direction. If a large quantity of blood 
escape at the wound, there is reason to apprehend the 
injury of some of the viscera (unless the wound be in the 
course of the epigastric artery.) If bile, fceces, or any of 
the usual contents of the viscera, make their appearance, 
there can be no doubt of a wound in an intestine. Very 
little is to be learned by examinations with probes, or 
even by passing the finger into the wound, and therefore 
unless some real good can result from it, it should be 
omitted. 

When a large blood-vessel is opened, and the blood 
does not find a ready exit through the external wound, 

* Adhesive plaster is also to be used, and over jt a compress and bandage. 



ELEMENTS OF SURGERY. g3 

great debility comes on, fainting, a weak faultering pulse, 
cold sweats, swelling of the abdomen, and, if the bleed- 
ing should not scop, death. 

Gunshot wounds of the abdomen in general occasion 
complicated mischief, the ball passing through the visce- 
ra, and wounding them in several places. If the ball pass 
with considerable velocity, sloughs must take place, and 
greatly enlarge the various openings it has made. " If 
the ball pass with less velocity, there will be less slough- 
ing, and the parts will in some degree heal by the first 
intention similar to those made by a cutting instrument ; 
but although the ball has passed with such velocity as to 
produce a slough, yet that wound shall do well, for the 
adhesive inflammation will take place on the peritoneum 
all round the wound, which will exclude the general ca- 
vity from taking part in the inflammation, although the 
ball has not only penetrated, but has wounded parts 
which are not immediately essential to life, such as the 
epiploon, mesentery, &c. and perhaps gone quite through 
the body ; yet it is to be observed that wherever there is 
a wound, and whatever solid viscus may be penetrated, 
the surfaces in contact, surrounding every orifice, will 
unite by the adhesive inflammation, so as to exclude en- 
tirely the general cavity, by which means there is one 
continued canal, tcherever the ball or instrument has 
passed; or if any extraneous body should have been car- 
ried in, such as clothes, &c. they will be included in these 
adhesions, and both these and the slough will be con- 
ducted to the external surface by either orifice.'' 

This quotation from Mr. Hunter explains the reason 
why so many patients get well of wounds in the viscera, 
and aifords a wonderful proof of the resources of nature,' 
in providing against danger and death. Unless adhesive 
inflammation arise and agglutinate the injured bowels to- 
gether, at the circumference of every aperture made into 



Qi, ELEMENTS OP SURGERY. 

them, death must inevitably result, from the escape of 
the contents of these viscera into the general cavity of the 
abdomen. 

From this view of the subject, and from repeated ex- 
perience, we learn that most of the viscera of the abdo- 
men may be wounded without fatal consequences. The 
gall bladder is perhaps an exception, because the acrid 
nature of its contents, and the facility with which the bile 
escapes whenever this viscus is punctured, cannot fail to 
occasion peritoneal inflammation; and we find no case 
recorded of a recovery after a wound penetrating the 
gall bladder. If any acrid substance escape from the 
stomach into the general cavity of the belly, as ardent 
spirit, &c. the same fatal consequences will result, of 
which I once saw a striking instance in a'man whose sto- 
mach was wounded after drinking porter. The wound 
of the stomach was found on dissection completely heal- 
ed ; the patient died on the fourth day of peritoneal in- 
flammation, ^z" 

The inflammation of the cavity of the belly which oc- 
curs whether the viscera be wounded or not, (unless the 
external wound be promptly united) calls for copious and 
active measures ; bleeding, purging, low diet and blisters, 
over the abdomen. In general these remedies, if com- 
menced early, and pursued actively, are found successful, 
and the inflammatory symptoms subside. In others it 
terminates in adhesions, connecting together the dijfferent 
viscera, coagulating lymph being poured out, on various 
parts of the peritoneal surface. In others suppuration 
takes place, and large quantities of matter are formed in 
the abdomen. Mortification also sometimes occurs, and 
consequently death. 

If the remedies for inflammation do not succeed in re- 
ducing it, and suppuration takes place, when its exist- 
ence is clearly ascertained, a lancet may be introduced, 



ELEIVfENTS OF SURGERY. Qj 

and afterwards a canula through which this matter may 
be evacuated. If no particular spot appear elevated 
more than the rest, the puncture may be made at the 
usual place where tapping for dropsy is performed, about 
two inches below the umbilicus. 

In some wounds of the abdomen a protrusion of some 
of the abdominal viscera takes place ; where the protru- 
ded parts are uninjured, it is always best to replace them 
as speedily as possible within the cavity. If they be 
wounded, or if from long exposure and the stricture m^de 
upon them by the wound, they are in a mortified state, 
other measures are necessary. Previously to replacing 
them all extraneous matter should be carefully removed. 
Dirt, clots of blood, and every foreign substance, must be 
washed off with warm water. I have seen a large portion 
of the colon, together with the omentum covered with 
sand and dirt mixed with blood, protruding from a large 
wound in the abdomen; great care was in this instance 
necessary to prevent the introduction of these irritating 
matters into the abdomen. 

It often happens that a considerable stricture is made 
upon the protruded parts, and of course difficulty is ex- 
perienced in reducing them. To facilitate it, the patient 
should be placed in such a posture as to relax the muscles 
of the abdomen. If the difficulty arise from distention 
with fceces or flatus, the contents may often be squeezed 
out, and the bulk of the intestine thus reduced. If, how- 
ever, the reduction be still difficult, it is highly improper 
to use any violence in attempting it; it is better to enlarge 
very carefully the wound witli a bistoury. 

The treatment of the case when a portion of the intes- 
tine is mortified, will be described in the chapter on her- 
nia, as it forms a very important variety of that com- 
plaint. 

Blood is sometimes poured out in considerable quanti- 



96 ELEMENTS OF SURGERY. 

ties by some large vessel within the abdomen. If the 
quantity be very great, swooning, and the usual debilita- 
ting effects of hemorrhage quickly ensue. If the patient 
survive these symptoms, the collection of blood is easily 
perceived forming a tumour in some part of the abdomen. 
The abdominal viscera are so closely in contact that a 
general diffusion of this blood among them seldom hap- 
pens ; it is found, on the contrary, collected into one 
spot; and this, according to Sabatier, is in tlie lower 
and anterior part of the abdomen, just above the pubis.* 
He remarks that, in general, upon opening bodies in 
which these extravasations have happened, the blood is 
found in every part of the cavity, but that this is entirely 
owing to carelessness in the dissection, and that a cau- 
tious proceeding discovers that it is collected in one 
mass, and that after a time it becomes firmly surrounded 
by the matter of adhesions, in consequence of inflamma- 
tion, forming a kind of sac or pouch. 

The changes which the extra vasated blood undergoes, 
coagulating and irritating the surrounding parts, occasion 
very distressing symptoms. In the first place pain, and 
tension of the part, followed by hiccough, costiveness, 
vomiting, and sometimes suppression of urine. Some- 
times by great weakness, a small feeble pulse, and cold 
sweats. 

To relieve these symptoms, it becomes necessary to 
make an opening for the discharge of the blood. A 
puncture is to be made with a lancet, or trochar, and 
a canula introduced; if the blood be fluid it will readily 
flow through it; when it is found coagulated, it has been 
recommended to inject warm water into the wound, in 
order to wash it out ; from the fact that injections of warm 
water in cases of hydrocele, effect a radical cure by ex- 

* .Mcflccliie Ojjcratoire, torn. i. p. 35. 



ELEMENTS OF SURGERY. giy 

citing inflammation, I have strong doubts of the pro? 
priety of this practice. 

When the contents of the viscera are extravasated, the 
only remedies which can be employed are the remedies 
for inflammation; rest, a low diet, bleeding, purging, 
&c. They sometimes form abscesses, and are discharged 
externally. I have known a piece of cheese which escap- 
ed from a wounded stomach, discharged after the wound 
had healed, by an abscess in the groin. 

WOUNDS OF THE ABDOMINAL VISCERA. 

The symptoms denoting wounds of the particular vis- 
cera of the abdomen are not always strongly marked, 
but in general we are able, from a careful investigation 
to ascertain with some degree of accuracy the parts in- 
jured. 

" From a wound in the liver there will be a pain in 
the part of the sickly or depressing kind ; and if it is in 
the right lobe there will be a delusive pain in the right 
shoulder, or in the left shoulder from a wound in the 
left lobe. 

" A wound in the stomach will produce great sickness 
and vomiting of blood, and sometimes a delirium. 

" Blood in the stools will arise from a wound in the 
intestine, and according to the intestine wounded it will 
be more or less pure ; if tlie blood is from a high part of 
an intestine, it will be mixed with foeces and of a dark 
colour; if low as the colon, the blood will be less mixed 
and give the tinge of blood ; and the pain or sensation 
will be more or less acute, according to the intestine 
wounded, more of the sickly pain the higher the intes- 
tine, and more acute the lower. 

" There will be bloody urine from a wound of the 
kidneys or bladder, and if made by a shot or ball and a 

VOL. I. 14 



98 ELEMENTS OF SLllGEUV. 

lodgment made, these bodies will sometimes become the 
cause of a stone. The sensation will be trifling. 

" A wound of the spleen will produce no particular 
symptoms, excepting probably sickness, from its connex- 
ion with the nerves of the stomach.^ (Hunter.) 

In the treatment of wounds in the stomach or intes- 
tines it must be evident that many cases occur where the 
part wounded cannot be exposed, or indeed known, and 
here nothing is to be done but to combat the inflammatory 
symptoms.* When a wound in the stomach can be seen, 
a number of stitches proportioned to its extent must he 
used, the ligatures cut off close, and the parts returned. 
In transverse wounds of the intestine, in which the great- 
er part of the canal remains entire, the experiments of 
Mr. Astly Cooper and other surgeons have proved the 
safety of closing the wound by the interrupted suture, 
and returning the gut into the belly. The stitches are 
separated by the actions of the absorbents, and pass 
readily through the intestinal canal, a coating of coagu- 
lating lymph being formed over them, which prevents 
their falling into the cavity of the peritoneum, and ex- 
citing inflammation there. A single stitch is generally 
sufficient to close a wound not extending more than half 
round the intestine, and it should be made with a com- 
mon round sewing needle armed M'ith waxed thread. 
Longitudinal wounds of the intestine, it has been be- 
lieved, do not heal so readily as those which are trans- 
verse. There is probably more danger of the escape of 
fceces from them, and they are not so readily closed. 
From some experiments of Dr. T. Smith, performed in 
this city, and published in his inaugural thesis in 1805, 

• The propriety of dilating the external wound to search for the wounded 
intestine is very douo-f.,i ; Ist. from the danger attending an enlargement of 
the woin\d, and 2dly, from the uncertainty of finding the injured viscus 



ELEMENTS OF SURGERY. yg 

it appears that in dogs even extensive longitudinal wounds 
may be reunited. 

It is proper in many such cases to cut out completely 
the wounded portion and unite the cut extremities- to- 
gether, because the longitudinal is thus converted into a 
' transverse wound. 

When the intestine is cut completely through, either by 
a removal of a mortified portion, or by the original wound, 
the divided extremities are to be secured by four stitches; 
the ligatures are to be left out at the external wound, and 
in a short time they unite, and an adhesion takes place 
connecting the intestine to the peritoneum at the wound- 
ed part. After five or six days, the threads, if loose, 
may be removed, as they become useless after adhesions 
take place. The practice of Mr. John Bell in these 
cases, of trusting to a single stitch, is full of danger, and 
ought never to be adopted. Mr. Cooper's remarks on 
the treatment of mortified intestine in his work on hernia 
are entirely applicable to the present subject. 

In most instances of wounded intestine the canal is 
diminished at the injured part, and cholicky pains are 
an occasional consequence. A great degree of constric- 
tion has in some cases resulted and terminated fatally, 
but in general the bowel regains its usual volume, and 
performs its functions as well as before the injury. 

In all cases where there is reason to believe that the 
bowels are wounded, it is important to prohibit the use 
of solid food, and confine the patient to barley water ex- 
clusively, or some mild drink. 

Wounds of the omentum or mesentery seldom occa- 
sion trouble, except from their bleeding; when practica- 
ble, the bleeding vessels are to be secured by li-^ature 
and the ligature in every instance left out at the external 
wound. 

Wounds of the gall bladder are, in the opinion of 



100 ELEMENTS OF SURGERY. 

most surgeons, necessarily fatal. A case is related iu 
the Edinburgh Medical Essays, in which the patient 
survived this accident a week. Before death the abdo- 
men became extremely tense; a rumbling noise was 
heard in it. The patient had no stools, notwithstanding 
the use of purgatives and glisters. Sleep could not be 
procured, although anodynes were exhibited. No fever 
appeared. The pulse was natural till the last day, wheil 
it became intermittent. Upon dissection the intestines 
were found much distended, the gall bladder quite empty, 
and a large quantity of bile, extra vasated in the abdomen. 
Sabatier relates a case in which bile was drawn off by a 
trochar from the cavity of the belly ; but no advantage 
resulted, and the patient died a few hours after it was 
performed, viz. on the third day. 

Wounds of the liver call for no particular treatment. 
They are generally, when extensive, fatal from hemorr- 
liage, owing to its great vascularity ; and if any of the 
branches of its excretory duct are punctured, the bile es- 
capes and occasions inflammation of the peritoneum. 
Small incised wounds of the liver often heal without dif- 
ficulty. 

Wounds of the kidneys are not fatal unless the urine 
escapes into the cavity of the abdomen. They call for no 
particular treatment. The patient generally voids bloody 
urine at first^ but the part soon heals. 



^ELEMENTS OF SURGERY. fQl 

CHAPTER XVI. 

Wounds of Joints. 

In these, as in other wounds penetrating cavities, it is 
of great importance to g:uard against inflammation, as the 
effects of violent inflammation in the larger joints, upon 
the constitution are very serious. 

In all cases of wounded joints it is important to place 
the limb in such a posture as to favour the approximation 
of the sides of the wound. Absolute rest is to be enjoin- 
ed, and a rigid adherence to the antiphlogistic treatment. 
Sutures are never to be used in these cases, if it be pos- 
sible to dispense with them, and when it is not, they 
must never be passed into tlie cavity of the joint, but only 
through the cellular membrane on the outside of it, for 
very obvious reasons. Treated in this manner, incised 
wounds of the larger joints very readily heal by the first 
intention, even when the articulating extremity of the 
bones are injured. 

When inflammation supervenes in consequence of a 
wound in a large joint, the constitution suffers severely : 
fever comes on, generally ushered in witb a great decree 
of nausea. Violent pain takes place in the joint, and an 
increased secretion of synovia, which is thinner and more 
watery than usual. The ligaments swell and become 
thickened by effusions of coagulating lymph. At length 
suppuration takes place, and pus is secreted from the 
wliole surface of the synovial membrane; ulceration comes 
on, and openings are formed in various parts of the skin 
covering the joint. 

The formation of an abscess in a large joint, as the 
knee or hip, never takes place without great danger to 



402 ELEMENTS OF SURGERY. 

the life of the patient. I have seen death occur in a very 
few days from inflammation of the knee, terminating in 
suppuration. Extreme pain, fever and delirium, gene- 
rally precede the fatal event. 

In those cases where the symptoms of inflammation do 
not terminate so speedily, ulceration of the ligaments is 
followed by inflammation of the bone ; the cartilage is ab- 
sorbed, and the whole joint destroyed; granulations arise 
from the inflamed bones ; they unite, and anchylosis is 
eiFected ; but these processes require a great length of 
time, and during this time the patient is affected with 
hectic fever, and great exhaustion from the continued dis- 
charge. Abscesses also form in the vicinity of the joint, 
and portions of carious bone or detached cartilage, are 
evacuated through them. Before anchylosis can in this 
manner be accomplished, the patient must inevitably suf- 
fer a tedious, painful confinement, under which the con- 
stitution often sinks, and a lingering death eventually 
concludes his sufferings. 

These terrible consequences sometimes result from 
simple incisions or punctures into joints, as well as from 
the more aggravated mischief of lacerated or gunshot 
wounds. They are only to be prevented by a most ac- 
tive employment of the remedies for inflammation already 
enumerated. 

On the first approach of inflammation, bleeding is to 
be performed, and carried to as great an extent as the 
patient's strength will warrant. Topical bleeding, by 
cupping or leeches, is next to be employed, and after this 
a blister should be applied large enough to cover the" 
skin over the joint. The blister in these cases should be 
applied earlier than is recommended by authors. I have 
seen the best effects from a speedy application of this 
remedy. 

In chronic inflammations of joints, either from wounds 



ELEMENTS OF SURGERY. 103 

or other causes, the repeated use of blisters is never to be 
omitted. Purging is also to be actively employed. 

In order more eft'ectually to procure absolute rest of 
the joints, it is advantageous in some cases to apply 
carved splints to fit the parts, and these being lined with 
soft materials, occasion no inconvenience. In wounds of 
the knee, ankle or elbow, these splints are particularly 
useful. 

When in consequence of the violence and continuance 
of the inilammaiion, there is reason to apprehend a stiff 
joint from anchylosis, it is necessary to choose the posi- 
tion of the limb, in which this stiffness will be least in- 
convenient to the patient, and to preserve that posture 
during the cure. If, for example, the elbow were to heal 
with the arm permanently extended, the limb would be 
almost useless, whereas an arm flexed at the elbow, even 
when the joint allows no motion, is extremely useful. lu 
the lower extremity on the contrary, a flexed posture 
would preclude the patient from walking, while an ex- 
tended leg, with a stiff knee, would be attended with 
comparatively little inconvenience. 

Lacerated and gunshot wounds of the joints are always 
attended with more danger than simple incised wounds, 
because in them the parts cannot unite so speedily, and 
the cavity remains longer imperfect. So great is the 
danger to tlie life of the patient, that it always becomes 
a serious question with his surgeon in such wounds of 
the elbow, knee, or ankle, whether an amputation ought 
not to be immediately performed. In addition to the dan- 
gers already enumerated, gangrene from the disorganiza- 
tion of the parts may occur, or life may be destroyed by 
tetanus. 

It is not easy to give any general rules by which to 
guide our decision of the momentous question of ampu- 
tation in wounth of joints. Undoubtedly many cases oc- 



104< ELEIVIENTS OF SURGERY. 

cur, in which the destruction of the surrounding parts, 
arteries, nerves, tendons, &c. together with the shattered 
state of the bones forming the articulation, especially 
when this complicated injury has occurred in the hot 
weather of summer, leaves no doubt of the propriety of 
immediately removing the limb ; but other cases occur iu 
which the main artery of the limb is not destroyed, and 
in which there is a prospect of saving the limb, provided 
the patient escape the dangers of gangrene, of tetanus, 
of inflammatory fever, of extensive suppurations, of hec- 
tic fever, &c. In cases of this kind the surgeon feels 
his responsibility to be great, and it requires an attentive 
consideration of every circumstance connected with the 
particular case to confirm his decision. All these circum- 
stances shoukl be stated to the patient and his friends, 
and they should assume the responsibility and conclude 
whether to attempt the saving of a limb, by incurring the 
dangers which must be encountered, or by an amputation 
to avoid them. 

The cartilages of a joint never either inflame, suppu- 
rate or ulcerate ; they are incapable of restoring them- 
selves when injured, and although flesh in some cases 
gi-ows over them, they never adhere to it. Mr. John Bell 
observes, " we amputate a toe at the joint, and the flaps 
unite in two days, but still they have united with each 
other only, and not with the cartilage at the joint; and 
in a luxated limb we find that the bone continues dis- 
placed, the cartilage never inflames, nor ever unites with 
the lacerated parts.'^ 



ELEMENTS OF SURGERY. 105 

CHAPTER XVII. 

Wounds of Serves and Tendons. 

In most of the systems of surgery which have been 
published, wounds of the nerves have been consider- 
ed as a subject of great importance, and many terrible 
consequences are attributed to punctures or partial divi- 
sions of them. 

The first symptom indicating a wound of a considera- 
ble nerve is severe pain, and afterwards a numbness, or 
diminution in the sensation and powers of the part to 
which the injured nerve was distributed. These symp- 
toms in general gradually subside, and no particularly 
bad consequence results from the wound. 

The inflammatory symptoms sometimes consequent to 
the operation of phlebotomy have been ascribed by many 
surgeons to punctures of a nerve or tendon. The true 
explanation of these effects we shall presently offer. 

The operation of cutting down to the nerve and divid- 
ing it entirely, is very seldom to be performed. The 
only case in which it is to be recommended is when after 
venaesection, the patient experiences violent pain, follow- 
ed by numbness of the arm, and where these symptoms, 
instead of subsiding after a few days, increase in severity. 
Under such circumstances an incision should be made 
througii the wound, and carried a Utile below it, by 
which in all probability any partially divided nerve would 
be completely cut through, and the symptoms, if derived 
from tliis source, would speedily cease. 

The necessity for this operation is, however, extreme- 
ly rare. I have never seen or heard of a case in this 
city (where blood-letting is a very frequent operation) in 

VOL. I. 15 



106 ELEMENTS OF SURGERY. 

which the symptoms have been such as to warrant any 
surgical operation for the division of a nerve. 

Tendons, when wounded, occasion no pain. There 
are many proofs that tendons in a healthy state possess 
little or no sensibility ; when inflaraed, they are often ex- 
quisitely sensible. It occasionally happens, however, in 
punctured wounds, that certain tendinous fasciae are 
pierced, and the soft parts below the expansion are also 
injured ; when these inflame, the stricture formed by the 
tendon occasions very severe pain, and greatly aggravates 
the inflammatory symptoms. In these cases a division of 
the tendinous fascise procures immediate relief. As the 
fasciae attached to the tendon of the biceps flexor cubiti 
is situated in the vicinity of those veins from which 
blood is generally drawn, there is reason to believe that 
in some rare cases this accident has happened in phlebo- 
tomy ; in such cases a small incision through the fascia 
could very readily be made. 

Wounds of tendons are to be treated as wounds in other 
parts, by keeping them at rest with their divided surfaces 
in contact. It happens to carpenters and ship joiners, oc- 
casionally to divide with a foot adze the tendo Achillis. 
When this accident happens, the foot is to be kept extend- 
ed by a splint secured by means of a roller in front of the 
leg, extending from just below the knee to the point of the 
toe ; compresses being applied to fill up the inequalities of 
the limb, the divided surfaces of the tendon are to be ac- 
curately placed in contact, and kept so six or eight weeks, 
when union will be effected; but several months must 
elapse before the patient attempts to support the weight 
of the body upon this tendon. The same mode of treat- 
ment is to be used in ruptures of the tendon. In wounds, 
however, the skin is apt to fall into folds, and insinuate 
itself between the cut surfaces of the tendon. To prevent 
this inconvenience, adhesive plaster should be applied in 
such a manner as to keep it pulled back from the wound. 



ELEMENTS OF SURGERY. IQy 

Dr. Monro's plan of dressing such an accident is 
equally successful. It consists in having a strap fastened 
to the heel of a slipper, and this strap buckled to a ban- 
dage fixed round the leg just below the knee. The roller 
on the leg prevents the action of the gastrocnemii muscles, 
by which the superior portion of the tendon would be 
pulled up, and the strap on the slipper keeps the foot in 
an extended position, by which the lower portion is pre- 
vented from being drawn down.* 

WOUNDS OF VEINS .f 

These generally occasion very little trouble ; the he- 
morrhage may be commonly stopped by compression. In 
some cases, however, the cavities of veins, like the other 
cavities of the body, take on inflammation, in consequence 
of the external opening not being united by the first in- 
tention. Mr. Hunter has published a very valuable paper 
on the inflammation of veins in the Medico- Chirurgical 
Transactions ; from this paper it appears that the swelling 
of the arm consequent to vensesection is generally occa- 
sioned by the inflammation of the inner coat of the vein. 
He has dissected the arm in some cases where patients 
have died from this disease, and has found in some parts 
of the vein adhesion, in others suppuration, and in other 
cases ulceration. 

In most cases when pus forms in a vein thus circum- 
stanced, adhesive inflammation having preceded the sup- 

* An accident of frequent occurrence, is a rupture of some muscular or ten- 
dinous fibres of the gastrocnemius muscle, attended with severe pain, ec- 
chymosis and subsequent inflammation ; the treatment is the same, but patients 
rarely submit to the confinement, in wliich case a tight roller applied so as to 
cover the leg affords great relief, and generally eflfects a cure. A paper on 
tliis subject may be seen inthe7tli vol. of the Medico-Chirurgical Transactions 
by Mr. Wardrop.— The author having tried his plan of treatment was com- 
pelled to lay it aside as inefficient; the roller being the only useful part of it. 

t The principal circumstances demanding attention in cases of wouxds of 
TUE AHTEHiis havc bccn already noticed in the chapter on hemorrhage. 



^Qg ELEMENTS OP SURGEUY. 

piirative stage, is found to have cut off all communication 
between the general circulation and the inflamed vein. In 
other cases, however, the pus is not thus excluded from 
the mass of blood, but is carried along with it to the heart, 
and occasions death. 

Aftei' an abscess is formed by adhesions closing up a 
portion of the vein, absorption takes place, and the coats 
of the vein are removed. The abscess then points, and 
matter appears under the cuticle. Mr. Hunter has seen 
instances of pus contained in the cavities of veins in many 
patients who have died after amputation, compound frac- 
ture, and mortification. It happens as frequently in 
healthy constitutions as in others, a proof of which is that 
if a patient with an inflamed vein be bled in the other 
arm, the wound heals without any such consequence. 

In some cases a considerable portion of the vein takes 
on inflammation; generally that portion between the 
wound and the heart, but sometimes the portion next the 
extremity ; a string of abscesses existing throughout its 
extent. When the parts get well, it is found that the ca- 
vity of the vein at the inflamed part has been obliterated, 
and the patient can never afterwards be bled in that 
place. 

Inflammation of a vein is sometimes an effect after 
bleeding horses, which is usually done in the neck. 
*' The operator on this animal does not always take suf- 
ficient care to close up the external wound, for although 
the method usually employed would at first sight appear 
a good one, that is by a pin passed through the wouud 
from side to side, as in the hare-lip, and overtied by a 
thread or hair ; yet if not executed with sufficient atten- 
tion, I am inclined to believe that it is the very worst, as 
it very readily promotes inflammation in the cavity of the 
vein, either of the adhesive or suppurative kind, according 
as the ligature does or does not communicate with the ca- 
vity." (Hunter.) 



ELEMENTS OF SURGERY. ^09 

Mr. Hunter has seen in some of these inflammations of 
horses the jugular vein inflamed through its whole length, 
the head greatly swelled, and the inflammation carried 
along the vein quite into the chest. Many horses die of 
this disease, but what is the particular circumstance 
which occasions their death is not ascertained. "^^ It may 
be either that the inflammation extends itself to the heart 
or that the matter secreted from the inside of the vein 
passes along that tube in considerable quantity to the 
heart, and mixes with the blood." 

In many instances the constitution is affected with vio- 
lent fever, and in some cases in the human subject death 
has resulted. Pus passing into the circulation adds, in 
Mr. Hunter's opinion, to the general disorder, and ren- 
ders it fatal. 

" Although the operation, which is the most frequent 
cause of this complaint, is in appearance trifling, yet, as 
it is verj^ often of serious consequence both to the life of 
the patient and the character of the surgeon, it requires 
particular attention in the operator to prevent as much as 
possible an evil of such magnitude ; with this view he 
will be particularly attentive to the mode of closing the 
wound and binding up the arm : this is to be done by 
bringing the two sides of the wound together, that they 
may unite by the first intention. To accomplish this let 
the surgeon with the thumb of that hand which holds the 
arm push the skin towards the orifice, while he draws it 
on the other side to the same point with the compress ; 
thus the skin will be thrown into folds at the wound, over 
which he is immediately to apply the compress, which 
should be broad to keep the skin better together, and 
thick to make the compression more certain." 

Mr. Hunter recommends a " compress of linen or lint, 
in preference to sticking plaster, for the blood drying over 
the orifice is a kind of bond of union more natural and 



110 ELEIVBENTS OF SURGERY. 

effectual than any other application, and this conclusion 
is drawn from practice," more sore arms being a conse- 
quence of bleeding where plasters have been used than 
when the arm has been dressed in any other way. 

" When inflammation takes place beyond the orifice, 
so as to alarm the surgeon, he should immediately make 
a compress upon the vein at the inflamed part, to make 
the two sides adhere together; or if they do not adhere, 
yet simple contact will be sufficient to prevent suppura- 
tion in this part ; or if inflammation has gone so far as to 
make the surgeon suspect that suppuration has taken 
place, then the compress must be put upon that part of 
the vein just above the suppuration." 

The remedy for inflammation of the veins consequent 
to vensesection, which answers best, is the application of 
a blister over the inflamed part. As soon as the inflam- 
mation commences, a small plaster of simple cerate, 
spread on linen, should be applied on the orifice, and 
over this a blister large enough to cover the whole inflam- 
ed part, extending three or four inches from the orifice in 
every direction. This remedy, I believe, was first intro- 
duced by Dr. Physick. It has been used by him for many 
years with constant success, and I have myself employed 
it repeatedly, and never without advantage. 

Should fever attend, purging and low diet should be 
ordered, and bleeding, if the inflammatory symptoms run 
high. A splint is sometimes useful to keep the arm at 
rest. 

The inflammation of a vein consequent to vensesection 
sometimes assumes a chronic form, and continues with a 
hard swelling and some pain for many weeks. Repeated 
blisters have been found extremely serviceable in these 
caseg. 



ELEMENTS OP SURGERY. 4|£ 

It is unnecessary particularly to describe the appear- 
ance of the inflamed arm consequent to vensesection, be- 
cause it is generally known to medical men. In its com- 
mencement it resembles somewhat an erysipelatous affec- 
tion, extending above and below the orifice made by the 
lancet, a tumor existing, however, at the part which is 
hard and painful; the arm cannot be bent or extended 
without great pain. In this state the blister very ge- 
nerally prevents the further progress of the inflamma- 
tion. 



iia ELEMENTS OF SURGERY. 

CHAPTER XVIII. 

Of Fractures. 

A FRACTURE is a breach in a bone, (or as it is gene- 
rally defined, a solution of continuity) produced by ex- 
ternal violence, or by muscular action, or by the conjoint 
operation of both. 

The bones most frequently broken are those of the 
extremities. Bones are broken in one or in several 
places ; when broken in more than one place, the frac- 
ture is said to be comminuted. 

Fractures may occur in the vicinity of joints, or in the 
middle of the bones of an extremity. In the fore arm and 
leg, one or both bones may be fractured. The fracture 
may be directly across the bone in a transverse direction, 
or it may be oblique, and the degree of obliquity may 
vary very much. 

Fractures differ in relation to the form of the bone, its 
importance, and uses. The broad flat bones, as the 
scapula or ilium, are rarely fractured. The bones of the 
scull, however, are more frequently broken than any 
other flat bones, and the importance of this accident 
transcends that of most others, from the effects of the in- 
jury upon the brain. The long bones are by far the most 
frequently fractured. 

When the long bones are broken, the place of fracture 
is a subject of some importance to be attended to in judg- 
ing of the effects of the accident and of the mode of treat- 
ment. In a fracture of the middle of a bone, the broken 
surfaces are less extensive, and therefore they move more 
widely one from the other, yet this kind of fracture is the 
least dangerous, because in such cases the cause is sel- 



ELEMENTS OF SURGERY. 113 

(lorn applied to the part fractured, and for that reason 
the siirrouiHling soft parts are injured equally seldom. A 
less force suffices to break the bone in its middle than at 
any other part. It is also certain that inflammation, stijBf- 
ness, and anchylosis are less likely to happen than when 
the bone is fractured near the articulation. 

Bones are sometimes broken within a joint ; the frac- 
tured patella is always an example of this. I have seen 
a fracture through the head of the thigh bone, and also 
through the head of tiie humerus. 

The relative situation of the fractured extremities it is 
of great importance to ascertain. In some cases of trans- 
verse fracture no derangement at all takes place, the parts 
supporting each other as though they were not fractured. 
I had one patient with a transverse fracture of the tibia, 
who could stand up and bear some of the weight of his 
body upon the injured leg; and Dr. Physick had a pa- 
tient who, although the grating of the bones was distinct- 
ly heard, before his limb was dressed, took off all the 
bandages and splints, under an idea that the doctor was 
mistaken. After walking, however, once or twdce over 
the floor, and being confirmed in his opinion, an unwary 
motion of his leg occasioned a twist, and it bent under 
him at the place of fracture. Sometimes the fragments 
in a transverse fracture are partially separated, and in 
the tibia we often find one fragment projecting a quarter 
of an inch or mo^c above the other, and yet a great part of 
the fractured surfaces remain in contact. This is less apt 
to happen when both bones of the leg or fore arm are 
broken, as in these cases a total separation and distortion 
of the limb generally takes place. In fractures of the 
thigh and arm the muscles generally draw up the inferior 
fragment, and thus shorten the limb, even when the frac- 
ture is tran**^ rse. 

VOL. h 16 



114 ELEMENTS OF SURGERY. 

In some cases a bone is broken in such a manner as to 
form an angle at the place of fracture. 

The principal causes of the derangement of the frag- 
ments are the force which produced tlie fracture, the 
weight of the body, or of the fractured limb, and the ac- 
tion of muscles. The force which produced the fracture 
will often occasion great derangement of the limb, as tiie 
kick of a horse. The weight of the arm in fractures of 
the humerus, and of the leg in fractures of the thigh bone, 
occasion a separation of the fragments. The weight of 
the foot, when the patient lies on his back, will occasion 
a rotation in a broken thigh or leg ; but the most power- 
ful of these causes is muscular action. 

^^ Of the muscles which surround a fractured bone some 
are attached to that bone in a great part of its length, and 
therefore in many cases to both portions of the fractured 
bone. Others extend from the bone which is superior to 
that fractured, to that which articulates with the lower 
portion, or to the lower fragment itself; there are still 
others which terminate in the upper fragment, the other 
extremity of which may be more or less distant: The 
muscles of the thigh offer examples of these three differ- 
ent dispositions. The triceps is attached to the whole 
length of the femur ; the biceps, semimembranosus and 
semitendinosus, descend from the pelvis to the leg, to 
which the lower part of the femur is articulated, and all 
the movements of which it obeys ; the great adductor 
muscle has its insertion in the lower part of the femur it- 
self; finally the psoas, iliacus, pectineus, &c. descend 
from the loins and the pelvis, and have their insertion 
near the superior extremity of the femur. 

" The muscles which are attaclied to both portions of 
the fractured bone, contribute very little to their change of 
situation, but may, however, draw them both to the'^sidc 



EI.EMENTS OF SURGERY. i 15 

on which they are inserted, and thus change the direction 
of the limb. The triceps, and more particularly its mid- 
dle part, acts thus on the fractured femur, and renders 
the thigh convex anteriorly. The brachialis anterior tends 
to produce the same effect when the humerus is broken 
below its middle part, but the change from the natural 
situation is principally owing to the muscles which are 
inserted into the lower portion of the fractured bone, or 
the limb with which it articulates. Let us suppose the 
fracture of the humerus between its superior extremity, 
and tlie insertion of the great pectoral muscle, this muscle 
aided by the latissimus dorsi and teres major, drawls the 
inferior portion inward and upward, and causes it to as- 
cend on the interior side of the upper fragment which 
rests motionless, on account of its shortness, and because 
the muscles which are inserted into it are not acted on by 
any cause that excites them to action. In the fracture of 
the neck of the femur, the superior fragment has no mus- 
cles inserted into it, and remains motionless in the articu- 
lating cavity ; those muscles which, on the contrai'y, are 
attached to the lower portion, draw it upward and back- 
ward, and render its being displaced in that direction inc- 
vilal)le. 

" The lower portion being acted on by the limb to 
which it is articulated, follows all its motions, and is lia- 
ble to be displaced by the action of the muscles which 
are inserted into it. Thus, in fractures of the body of the 
femur, the biceps, semitendinosus, and other muscles, 
draw the leg, and with it the inferior portion, upward, 
inward, and backward, and cause it to ascend on the in- 
ternal, and a little on the posterior side of the superior 
portion, the inferior extremity of which projects, in that 
case, on the anterior and external side. 

" In the fracture of the leg, the gastrocnemii muscles, 
&c. draw the inferior portion upward and backward, with 



\lQ ELEMENTS OF SURGERY. 

the foot; for m this, as in every similar case, the strong- 
er muscles displace the lower portion of the fractured 
bone, and draw it in their direction : hence it is, that in 
this case the portion is drawn backward as well as up- 
ward, because the muscles are more numerous and larger 
on the back part of the leg than on any other. Therefore, 
when a fracture takes place in any part of a bone, it is 
easy to determine, from a knowledge of the muscles, 
what species of derangement w ill follow, if there be no 
counteracting cause. Finally, the muscles which have 
their insertion in a superior fragment, may produce its 
separation from the inferior. When the femur is fractur- 
ed immediately below the small trochanter, the iliac and 
psoas muscles draw forward the inferior extremity of the 
superior fragment, which raises the skin, and projects 
more or less. It is to be observed, however, that the dis- 
placing of this fragment is very rare, whilst the inferior 
fragment is displaced in almost every case." — (Boyer.) 

Fractures are more or less accompanied with laceration 
and injury of the surrounding soft parts. When the in- 
teguments covering the fractured bone remain entire, 
even although there be a great degree of laceration un- 
derneath it, the fracture is called simple. A compound 
FRACTURE is that in which an external opening is formed, 
communicating with the space between the broken extre- 
mities of the bone, or as it is commonly called, tlie cavity 
of the fracture. Mr. Hunter has applied the appellation 
of COMPOUND SIMPLE fractures to those in which a frac- 
ture originally compound becomes simple by the immedi- 
ate healing of the external wound. 

It sometimes happens that fractures are accompanied 
with dislocation, the dislocation probably in every case 
preceding the fracture. 

The CAUSES of fracture are the endless varieties of 
accidental force applied to bones. Certain circumstances 



ELEMENTS OF SURGERY. I (y 

of constitution, however, may be considered as predis- 
posing causes, such as old age, in which the bones are 
more brittle than in youth. Any morbid state of the sys- 
tem which occasions absorption of parts of the bony 
structure. The French surgeons* have recorded cases 
where bones have been broken by simply turning in 
bed. Cold weather has been supposed to predispose to 
fractures. Boyer observes, that if these accidents are 
more frequent in winter than in summer, it is because 
persons are then more liable to injuries from falling. Dr. 
Physick has offered a much more plausible explanation 
of the fact, which is, that in walking over frozen pave- 
ments and otiier slippery places, great exertions are often 
made to prevent falling, and this muscular exertion, add- 
ed to the force of the fall, occasions the fracture. The 
bones are too well covered to feel much influence from 
the cold. 

The SYMPTOMS of fractures it is very important to be 
acquainted with. They are severe sudden pain — an 
alteration in the form of the part — sometimes a shorten- 
ing of the limb, if the fracture be in an extremity — an in- 
ability to move the limb without severe pain at the in- 
jured part — an inequality of the skin covering the bone; 
which renders a fracture of the clavicle, or of the tibia, 
generally easy to be discovered; crepitation is the most 
certain of all the symptoms — a grating noise, not to be 
mistaken for any other sound, which is sometimes very 
audible. The surgeon should take hold of the limb above 
and below the fracture, and by moving the fractured ex- 
tremities of the bone, he produces this noise and decides 
beyond doubt the existence of the fracture. 

If, however, the surgeon be not called till swelling 
from ccchymosis, and inflammation have come on, it is 

* Louis and Saviard. 



lis • ELEMENTS OF SURGERY. 

not easy always to judge wliether a fracture exists; in 
this case he must wait until these symptoms subside. 

In judging of the probable event of a fracture, a great 
variety of circumstances influence the surgeon. The 
age of the patient is of great consequence; in young per- 
sons they heal much more speedily and certainly than in 
the ased. I have seen several fatal cases of simple frac- 
ture in old persons. A healthy constitution, not debili- 
tated by intemperance, is favourable for the healing of 
broken bones. Drunkards often become delirious and 
die, in consequence of fractures and other severe acci- 
dents. The nature of the accident, the degree of vio- 
lence applied, and the mode of its application, greatly 
influence tlie prognosis. Fractures from gunshot are 
always dangerous, a portion of bone being destroyed by 
the force of the ball, which must exfoliate (be separated 
by the absorbents) before the sound bone can granulate 
and unite : a compound is always more dangerous than a 
simple fracture. A fracture attended with great ecchy- 
mosis, and extensive injury of the adjacent flesh, is more 
dangerous than one unattended with these circumstances. 
An oblique is more difficult to manage than a transverse 
fracture. Fracturtu of the lower extremities have more 
serious consequences than those of the upper. In general 
those of superficial bones are less important than tliose in 
which the fracture is covered by large strong muscles. 
Fractures in the middle of a bone are less dansjerous than 
r* its extremities in the vicinity of joints. The season of 
the year, and many other circumstances, will no doubt 
affect the healing of broken bones. 

The reunion of fractured bones is effected nearly in 
the same manner as the restoration of soft parts. The 
inflamed vessels pouring out coagulating lympb, which 
becomes vascular, and is gradually by a deposition of 



ELEMENTS OF SURGERY. ^|9 

bony matter and an absorption of the unnevCessary parts, 
converted into a bone. 

Tiie uniting medium is called callus; it is at first soft, 
but gradually becomes firmer, and at length completely 
ossifies. 

In some cases the bond of union is very slow in form- 
ing, and then the inflammatory action must be increased 
by stimulating remedies. In other cases too much inflam- 
mation exists, and then unless prevented by depletion, 
suppuration takes place. 

OF THE TREATMENT OF FRACTURES, 

To place the fragments as nearly as possible in their 
original position, and to keep them so until union is effect- 
ed, are the important indications in the treatment of frac- 
tures. 

To effect the replacement of the fragments, extension 
and counter-extension are generally necessary, though in 
some cases, as in fractures of the olecranon and patella, 
the fragments are to be pushed together. After the parts 
are placed in their proper position, the application of 
bandages and splints becomes necessary to retain them 
so. Extension signifies the force exei ^ed on the fragment 
of a limb most remote from the body. Counter-extension 
is tlie power by which the opposite fragment is prevented 
from moving with it. The various modes of applying 
these forces will be most properly considered, when the 
treatment of particular fractures is described. 

The constitutional treatment must be regulated by va- 
rious circumstances. Inflammation frequently attends a 
fracture, and is an essential part of the process of resto- 
ration. If it be too violent, the surgeon must restrain it 
by the usual remedies. Purging in many cases of frac- 
ture is extremely inconvenient in consequence of the mo- 
tion to which it gives occasion. Blood-letting is to be 



120 ELEMENTS OF SURGERY. 

preferred, as this mode of evacuation is not liable to any 
objection, and the bowels are to be kept from costiveness, 
but no cathartics should be administered, unless in those 
fractures in which absolute rest is not enjoined, and the 
patient on the contrary is permitted to walk, as fractures 
of the arm, clavicle, &c. Alow diet should be observed. 

When the soft parts are much injured, the antiphlo- 
gistic measures are to be carried further than where the 
only injury is the broken bone. In many cases, by their 
powerful application, we prevent ulceration which wouhl 
convert a simple into a compound fracture. In cases of 
extensive ecchymosis, where no large artery is wounded, 
cold applications and copious depletion are generally suc- 
cessful in preventing the formation of an abscess. 

If any particular artery of considerable magnitude is 
wounded, it becomes necessary to cut down to it and tie 
it up ; and if possible without cutting into the cavity of 
fracture. 

In every case of fracture in which it is necessary for 
the patient to remain in bed during the cure (and there 
are very few in which it is not) a proper bed is an ob- 
ject of great convenience. Sir James Earle has publish- 
ed an account of a bedstead and mattress invented by his 
son, which in fractures and various other accidents and 
diseases, adds so greatly to the comforts of the patient, that 
I think the medical world are under great obligations to 
the inventor.* In private practice, however, and espe- 
cially in the country, it is extremely difficult to procure 
such a convenience, and then a firm common mattress of 
hair is to be substituted, or if this cannot be obtained, a 
few blankets folded and applied over boards. A feather 

♦ In the Pennsylvania Hospital, I have constantly used this bed in cases of 
fracture for several years, and have found it extremely convenient in the treat- 
ment of a variety of other accidents. An improvement on this apparatus by Dr 
J. R. Barton, is described in the 4th vol. of the Eclectic Repertory. 



PLATE in 



Ktnt^'A /ifd . 





mm\mmv\\m\A ir",;!l 



ELEMENTS OF SUBGERY. ^2£ 

bed and sacking bottom afford so very unequal and un- 
steady a surface, that it is extremely difficult to keep the 
patient wlio lies on them in a proper posture. 

OF COMPOUND FRACTURES. 

These have an external wound communicating with 
the cavity of the fracture. Mr. Pott very judiciously re- 
marks that, " [n tliis kind of case the first object of con- 
sideration is, whether the preservation of the fractured 
limb can, with safety to the patient's life, be attempted; 
or, in other words, whether the probable chance of de- 
struction, from the nature and circumstances of the acci- 
dent, is not greater than it would be from the operation 
of amputation. Many things may occur to make this the 
case ; the bone or bones being broken into many different 
pieces, and that for a considerable extent, as happens 
from broad wheels or other heavy bodies passing over 
or falling on such limbs, the skin, tendons, muscles, &c. 
being so torn, lacerated and destroyed, as to render gan- 
gicne and mortification the most probable and most im- 
mediate consequence; the extremities of the bones form- 
ing a joint being crushed, or as it were, comminuted, and 
the ligaments connecting such bones being torn and spoil- 
ed, are, among others, sufficient reasons for proposing and 
for performing immediate amputation ; reasons which, not- 
withstanding any thing that may have been said to the 
contrary, long and reiterated experience has approved.'^ 
^^ When a surgeon says that a limb which has just 
suffered a particular kind of compound fracture ought 
ratlier to be immediately cut off than that any attempt 
should be made for its preservation, he does not mean by 
so saying tliat it is absolutely impossible for such a limb 
to be saved at all events; he is not to be supposed to 
mean so much in general, though sometimes even that 
will be obvious; all that he can truly and justly mean is, 

VOL. I. 17 



i^Z ELEMENTS OF SURGERY. 

that from the experience of time it has been found that 
the attempts to preserve limbs so circumstanced have most 
frequently been frustrated by the death of the patients in 
consequence of such injury, and that from the same ex- 
perience it has been found that the chance of death from 
amputation is by no means equal to that arising from such 
kind of fracture. 

<* Every man knows that apparently desperate cases 
are sometimes cured, and that limbs so shattered and 
wounded as to render amputation the only probable 
means, are sometimes saved. This is an uncontroverted 
fact, but a fact which proves very little against the com- 
mon opinion, because every man of experience also knows 
that such escapes are very rare, much too rare to admit 
of being made precedents, and that the majority of such 
attempts fail. This consideration relative to amputation 
is of the more importance, because it requires immediate 
determination ; every minute of delay is in many instan- 
ces to the patient's disadvantage, and a very short space 
of time indeed makes all the difference between probable 
safety and fatality." 

It is not easy to give general rules for practice in these 
cases, or else Mr. Pott, and other writers of great prac- 
tical experience, would certainly have expressed them- 
selves with more precision. One evades the question, 
another gives it very little attention, and Boyer (inferior 
to none in a knowledge of the subject) says, ^^ It is im- 
possible to establish any general rule for cases of this 
kind. The surgeon must be directed by his own talents 
and sagacity in each particular case." There are, how- 
ever, some cases of compound fracture which so evident- 
ly call for amputation that no doubt need exist as to the 
propriety of performing it immediately, if the surgeon h 
called within a few hours after the accident has happen- 
ed, and before inflammation has commenced. These are, 



ELEMENTS OF SURGERY. Igg 

when a luxation of a large joint, as the knee, ankle, 
elbow or wrist, accompany the fracture, forming what 
has been called a compound dislocation ; when the prin- 
cipal blood-vessels of the part are destroyed, and thus 
the danger of gangrene augmented ; w hen a large lace- 
rated wound exists, the bone being greatly comminuted, 
part of its substance destroyed, and the weather very 
hot. In such cases, the dangers are to be stated, and the 
patient and his friends advised to submit to the operation; 
a mere compound fracture never calls for it ; it is the ad- 
ditional injuries which may require so terrible a re- 
source. 

Mr. John Bell remarks, " I am sorry to observe this 
the most important question perhaps in surgery, treated 
as if it were no question, but rather a rule of practice, 
which might be established on the most absolute grounds. 
When a surgeon condemns a limb, he does not say that 
if amputation be not instantly performed the patient will 
die, nor is he disappointed if the limb be saved; he 
thinks both more sensibly and more humanely; he knows 
that there is great danger of losing the patient's life in 
attempting to save his limb, and reckons it his appointed 
duty to advise amputation ; but he is still sensible that 
the limb may possibly be saved, and often after his honest 
opinion is rejected, contributes, by his attention and kind- 
ness, to that most desirable object. Sometimes he feels 
it his duty to advise amputation, and to represent very 
strongly the manifold dangers of attempting to save the 
limb, while yet he rejoices to find his patient willing to 
liazard all those dangers in favour of an object which it 
must be the chief honour of the surgeon to accomplish.'' 

The wound communicating with the fracture is some- 
times made by the protrusion of the bone, at other times 
by the same force which caused the fracture ; the latter 
cases are generally accompanied with the greatest mis- 



124 ELEMENTS OF SURGERY. 

chief. If, however, the injury be not so great as to iu. 
duce amputation, the bone is to be reduced, and proper 
dressings are to be applied. 

Sometimes a considerable portion of bone protrudes 
through the external wound, and cannot readily be re- 
duced. It has been the custom in these cases to cut off 
the sharp ends and projecting pieces of bone, but this is 
almost in every instance unnecessary, and therefore im- 
proper. By carefully attending to the posture of the 
limb, and by dilating the wound when the bone becomes 
girded in it, and embraced tightly, we may always suc- 
ceed in the reduction. The enlargement of the wound 
thus occasioned does much less mischief than violent at- 
tempts to reduce the bone, which always occasion bruis- 
ing and great pain ; an incision down upon the bone with 
a scalpel, or from the bone outward with a narrow bis- 
toury (whichever may in the particular case be found 
easiest) is to be performed; this incision readily heals, 
and leaves the wound no larger than it would have been 
if this had been omitted. Any loose splinters of bone 
may be removed, and the fragments carefully placed in 
contact. The wound, if an incision, may be closed with 
adhesive plaster. Mr. Hunter prefers, however, the ap- 
plication of a superficial dry compress, in order to allow 
the blood to coagulate and form a kind of scab, shutting 
up the cavity of the fracture. I have found both methods 
successful, and prefer the latter iu all cases except where 
the w^ound of the integuments is somewhat extensive, in 
which case a strip of adhesive plaster should be applied 
over the middle of the wound, leaving an opening at each 
end for the evacuation of effused fluids. We are always 
to keep in mind the gi-eat importance of uniting the 
wound by the first intention, and thereby converting the 
accident to the state of a simple fracture, by which much 
danger and suffering will be prevented. Whatever cir- 



ELEMENTS OF SURGERY. J^9j 

riMiistances, therefore, can keep the parts in a situation 
favourable for union by the first intention, are to be strict- 
ly observed, of course whatever can prevent the inflam- 
matory action from transcending the adhesive grade ; 
copious blood-letting is often necessary in these cases. 

In fractures occasioned by gunshot, and in others 
where union by the first intention is impracticable, and 
suppuration must take place, from the extensive contu- 
sion and injury of the surrounding flesh, a soft poultice 
of bread and milk should be applied. 

The wound being dressed, the accident is to be treated 
as a simple fracture, and of the proper dressings we shall 
speak after describing the fractures of particular bones. 

When extensive suppurations come on, and exfolia- 
tions of bone, the state of the patient's constitution will 
direct the general remedies. If debility be occasioned, 
bark and tonics must be administered, and a generous 
diet with fermented liquors allowed. 

The length of time necessary for the reunion of a bro- 
ken bone varies at dijBlerent ages and in different bones. 
In a healthy adult a broken leg will generally heal in six 
weeks, a broken rib or clavicle in four. In children they 
heal in a shorter time. In old persons not so soon. 

Notwithstanding the use of the proper remedies, cases 
sometimes occur in Avhich fractures do not heal by form- 
ing bone, but by a ligamentous union. The patella gene- 
rally heals in this manner, and no inconvenience results 
from a deficiency of bone between the fragments in that 
particular instance; but whenever this happens in one of 
Uie long bones, motion is allowed at the place of fracture, 
and a joint is formed, which destroys in a great measure 
the use of the limb, and exposes the patient to great in- 
convenience. In order to obviate this inconvenience, and 
to occasion bony union, a variety of measures have been 
resorted to. 



126 ELEMENTS OF SURGERY. 

The physiological account of the formation of callus 
is a subject foreign from our present purpose ; it is still, 
however, necessary to keep in view, that inflammation is 
essential to the restoration of a fractured bone, as well as 
of a wounded muscle. Whenever, therefore, two months 
or more have elapsed, without solid union being effected, 
it becomes necessary to excite inflammation by rubbiug 
forcibly the fractured ends against each other; after which 
the dressings are to be re- applied, and the part kept still. 
If this fail of procuring tlie desired event (and it some- 
times does fail) other measures of a much more active 
nature become necessary. Mr. Boyer, and other writers 
who have preceded him, recommend the cutting off of the 
extremities of the bone, and placing them again in con- 
tact. " This operation," he observes, "^ is painful, teni- 
fying, and of dubious event. Its success, however, has 
been frequent enough to warrant the trial. It would be 
impracticable in fractures of the leg or fore arm, on ac- 
count of the difficulty of separating from the integuments 
the two bones of which each of these parts is formed, and 
on account of the numerous nerves aud arteries which 
would be in danger of being wounded by the large in- 
cisions, it is therefore practicable only in the femur and 
humerus^ especially in the latter.^^ 

Mr. Boyer describes an operation of this kind which 
he once performed in the middle of the humerus ; the limb 
mortified, and the patient died on the sixth day ! In many 
other cases amputation has been performed. I saw an 
arm cut off in one of the largest hospitals in Europe in 
consequence of an " artificial joint" in the middle of tlie 
radius. It must be stated, however, that in this case 
there was a great deal of pain experienced in the part, 
but I do not consider this by any means an excuse for 
such an operation, because there is every reason to be- 
lieve that had the firm reunion of the fragments been 
effected, this pain would have subsided. 



ELEMENTS OF SURGERY. Igy 

Mr. John Hunter suggested the propriety of exposing 
the cavity by an incision, under an idea that the " stimu- 
lus of imperfection" would excite a sufficiency of inflam- 
mation to effect a union of the fragments. 

Dr. Physick has the credit of having proposed and 

practiced a mode of cure in these cases more eligible and 

successful than any heretofore in use, and one which 

promises to supersede the cruel and fatal operations 

which have been mentioned. It consists in passing a 

seton between the fragments, and suflfering it to remain 

until bony union commences. The first case in which this 

plan was carried into effect, occurred in the year 1803. 

The OS humeri had been fractured many months before, 

and a joint was formed in its middle, which rendered the 

arm useless. A seton needle armed with a skein of silk 

was passed through the limb (extension being made at 

the time by two assistants) between the fractured ends of 

the bone, a pledgit was applied on each orifice made by 

the needle, which was cut off, leaving the silk in the 

wound. The operation occasioned very little pain, and 

the subsequent inflammation was by no means violent, 

and was followed by moderate suppuration; the arm was 

in a few days after the operation placed in splints ; the 

dressings were renewed daily /o?* twelve weeks, during 

which time no amendment was perceived; but soon after, 

the bending of the arm at the fracture was observed to 

be more difficult, and the patient complained of more pain 

when it was moved. From this time the bony union 

went on gradually, and in about five months the cure 

was completed, leaving the arm as well and strong as 

it ever had been. 

Several cures of the os humeri and tibia have since 
been made in the same manner. It is important to be 
recollected that a long continued inflammation must be 
kept up in these cases, and therefore the seton should not 



1^8 ELEMENTS OF SURGERY. 

be withdrawn for four or five months unless bony union 
is found commencing. I am sorry to state that the reme- 
dy has been applied to two cases of fractured os femoris 
without effect; the occasion of the failure was, however, 
very obvious in both cases : it was found impossible to 
place the fractured extremities nearly together. They 
had passed each other to a considerable distance, and 
the adjacent lacerated flesh had healed around them ia 
such a manner, that a great intervention of soft parts ex- 
isted, and precluded completely all contact of the frag- 
ments.* My friend Mr. Brodie of London, has suc- 
ceeded completely in a case of fractured os femoris, by 
means of the seton, and believes it applicable to that as 
to other cases. Mr. Wardrop found it useful in dimin- 
ishing the mobility of the artificial joint, but the ill health 
of his patient prevented it from effecting a complete cure. 
(SeeMedico-Chirurgical Transactions, vols. 5 and 70 

It is probable that the remedy will be found effectual 
in most other cases of artificial joints, but not often in 
those situated in the os femoris. 

Much of the substance of the bone is absorbed in cases 
of artificial joints, so that the fragments are rounded, or 
rather pointed, and terminate in a kind of cartilage or 
ligament, t 



* See plate VI. fig. 6. 

t In a thesis published at Paris, by J. B. La Roche, in 1805, the seton, as 
proposed by Dr. P. S. Physick, is recommended as preferable to all other 
means heretofore used in such cases; but the writer being unacquainted with 
the English language, has supposed the family name of Dr. Physick to be that 
of his profession, and consequently ascribes the honour of the invention to 
Monsieur P. S. , Physician. The writer of the thesis alluded to, hav- 
ing seen setons used after gunshot fractures to facihtate the discharge of dead 
bone, wonders that the thought never occurred to himself nor his master, of 
applying the remedy to cure artificial joints. 



ELEMENTS OF SURGERY. |29 

CHAPTER XIX. 

Particular Fractures. 

FRACTURES OF THE OSSA NASI. 

The ossa nasi, in consequence of their exposed situa- 
tion, are often fractured. " The cause of the fracture is 
always applied to that part immediately where the solu- 
tion of continuity takes place, and the fracture may be 
oblique, longitudinal, or transverse, without derangement 
of the fragments; but it more frequently happens that 
the bones are splintered and crushed into the cavity of 
the nostril: the nose loses its natural form, and the 
neighbouring soft parts are much bruised by being crush- 
ed between the bones and the cause of the fracture, whe- 
ther this be a body against which the nose has been for- 
cibly struck, or one which may have been strongly im- 
pelled against it. 

" If the soft parts have suffered no solution of conti- 
nuity, and if the fragments have not been displaced, the 
fracture may not be discovered, because the form of the 
nose does not change. An oversight in this case is not 
dangerous, as the use of emollients and resolvents is all 
that is required. If the fracture be comminutive, not only 
the inflammatory symptoms ought to be combatted by 
blood-letting and other antiphlogistic means, but further, 
the fragments ought to be replaced, as they strain and 
irritate the soft parts, already contused, by their unnatu- 
ral situation. For that purpose the surgeon takes a 
gi-oovcd sound, a female catheter, a ringhaudled forceps, 
or any such instrument, introduces it into the nostrils, and 
by using it as a lever, pushes the fragments outwards; at 

VOL. I. 18 



130 ELEMENTS OF SURGERY. 

the same time with the index of the left hand applied to 
the ringe of the nose, he prevents them from being push- 
ed out too far, and from lacerating the integuments. 
Sometimes the bones continue in the situation in which 
they have been thus placed ; but it may happen, that 
from being much fractured, and badly supported by the 
soft parts, they fall again inwards : in which case a ca- 
nula of elastic gum should be directed along the inferior 
surface of each nostril, which ought then to be stuifed 
with lint, and gently thrust in, lest the pituitary mem- 
brane should be hurt. 

^^ In cases of comminuted fracture, with depression of 
the splinters, it would be imprudent to wait the disap- 
pearance of the inflammatory symptoms, before making 
an attempt to raise and. adjust the fragments; because, 
during the interval, the portions of bone might reunite 
in an unnatural situation, and produce deformity of the 
nose. 

" Fracture of the nasal bones is sometimes attended 
with very dangerous symptoms, whether produced by 
a violent commotion given to the head, by the cause 
of the fracture, or by a co-existing fracture of the bones 
of the skull ; or, as some authors think by the concus- 
sion communicated to the perpendicular part of the eth- 
moidal bone, and thence to its cribriform part, which 
would, in that case, be fractured, on account of its great 
tenuity. The laceration of the dura mater and its ves- 
sels, caused by the fracture of tlie cribriform lamella of 
the ethmoidal bone, would produce effusion, and thus 
give rise to all the symptoms. It is certain tliat cases 
have occurred where blows on the root of the nose have 
produced coma, convulsions and death ; particularly when 
the nasal bones were not fractured." (Boyer.) 

A piece of leather spread with adhesive plaster as- 
sists, by gentle compression, in preventing the displace- 



ELEMENTS OF SURGERY. j[3| 

mettt of the fragments, and as there is no danger of dis- 
placement from muscular action, no other dressing is 
necessary. I have seen a fracture of these bones in 
which one of the fragments punctured the facial ar- 
tery as it passes over the nose. The hemorrhage at first 
was very profuse, but ceased after the fragments were 
reduced. 



13S ELEMENTS OF SURGERY. 

CHAPTER XX. 

Fractures of the Lower Jaw. 

This bone from its moving freely when struck, and 
also from its strength of texture is not very often frac- 
tured. It sometimes however is broken, and no part of 
it is secure from fracture. Mr. Boyer declares that its 
" symphysis at the chin is very rarely fractured though 
it is not impossible." I once saw an instance of fracture 
at this place. Sometimes it is broken in several places. 
I have known the jaw bone broken by a fall, into five 
different fragments. The middle piece in these cases is 
most difficult to be kept fixed, because of the muscles in- 
serted into it which tend to draw it downwards. 

It is liable to fracture in every part, from the condyles 
to the chin. The coronoid process is not often fractured 
except by gunshot wounds. The condyles are oftener 
broken. The fracture may vary greatly in its direction; 
it is sometimes transverse, sometimes oblique, sometimes 
in the direction of the bone, or longitudinal, separating 
the alveolar portion from the basis. It is generally sim- 
ple, but sometimes compound. 

The symptoms of a fractured jaw are very obvious ; a 
severe pain at the part is felt at the time of the accident, 
and an inequality is perceived on passing the fingers 
along the basis of the jaw; upon examining the teeth 
they are found unequal, those situated upon one frag- 
ment being elevated above those of the other; when the 
two sides are taken in the hands it is easy to reduce 
the teeth to their proper level, and in doing so crepita- 
tion is perceived. These symptoms exist when the frac- 
ture is situated anteriorly to the angle of the jaw, when 



ELEMENTS OF SURGERY. 133 

the condyles are broken, the fracture is not so very ob- 
vious, but may be ascertained by pain near the ear when 
the jaw is moved, and by crepitation occasioned by these 
motions. If considerable swelling occur before the sur- 
geon is called, greater difficulty is experienced in deter- 
mining tlie nature of the accident, and in these cases it 
becomes necessary to wait until the inflammatory symp- 
toms subside. 

The greatest danger attending a simple fracture of the 
lower jaw is that of consequent deformity, and this is 
very readily obviated by proper arrangement. Compound 
fractures, however, are more dangerous and are often 
followed by tedious exfoliations, and in some instances 
do not unite. 

To reduce the fracture, nothing more is necessary than 
to shut the mouth, and forcibly push upwards the infe- 
rior fragment, until the teeth contained in it come in con- 
tact with those in the upper jaw. When all the teeth are 
upon a level, the fragments are to be supposed in appo- 
sition. It is not easy in all cases to keep them at rest in 
this position : — A variety of means have been contrived 
to effect this purpose, such as fastening the pieces to- 
gether by passing wire around some of the teeth in each 
— forming a mould of moistened pasteboard to fit the chin, 
and binding this fast upon it. The simplest and best 
plan is to avail ourselves of the support given by the 
teeth in the upper jaw, by binding the fragments firmly 
against them, and this can be very conveniently done by 
means of a simple roller of muslin passed repeatedly 
round the top of the head and under the chin. It may- 
be further secured by passing a few turns of it round 
the back of the neck and in front of the chin. The four- 
headed and double-headed bandages formerly used for 
this purpose, have no advantage over the roller, and it 
is by no means so easy to apply them neatly. 

The patient should be nourished fifteen or twenty days 



13* ELEMENTS OF SURGERY. 

on spoon victuals, sucked between the teeth, for which 
there is generally space enough, and this space is often 
augmented by the want of a tooth at some part of one of 
the jaws. — It has been proposed in comminuted and 
compound fractures, where the slightest motion is piH). 
ductive of great pain, to pass a catheter through th* 
nostril, and inject the fluid aliment through it. If a case 
requiring such treatment should occur, no difficulty would 
be found in effecting it. 

In fractures of the condyles of the jaw, that process is 
drawn forwards by the pterigoideus externus muscle; 
as it is very short there is no means of obviating this, 
and it becomes necessary therefore to push forward and 
keep in that situation the inferior fragment; in order to 
effect which, before applying the bandage as has been 
directed, a compress is to be applied behind the angle of 
the jaw extending nearly up to the ear, this compress 
when the roller presses tightly on it will keep the infe- 
rior fragment advanced sufficiently to come and remain 
in contact with the upper. In fractures of the condyles 
it is pa^rticularly necessary for the parts to remain at rest, 
as motion has sometimes prevented the reunion of the 
fragments and the condyle has exfoliated. Boyer relates 
a case in which this unpleasant event occurred : he ex- 
tracted the condyle seven months after the accident 
through a fistulous ulcer. 

Compound fractures of the lower jaw, are very fre- 
quently attended with exfoliation, by which the cure is 
much protracted. 

It often happens that one or more of the teeth are 
loosened at the fractured part; it has been advised to 
extract all loosened teeth, as extraneous matter. It is a. 
fact, however, that the teeth under these circumstances 
very readily become fixed, and it is extremely improper 
to remove them, because the accident is thus converted 
into a compound fracture. 



ELEMENTS OF SURGERY ^35 

CHAPTER XXI. 

Fractures of the Vertebrce. 

The spinal column moves readily in every direction, 
and being coti,posed of a great number of separate pieces^ 
of small size, is not very liable to fracture. The spi'^.ous 
processes are sometimes In'oken, because they are more 
slender and brittle than the other parts of the bone, pro- 
ject considerably backwards and are more superficial. 
Whenever the vertebrae are fractured, tlie force which 
produces this effect occasions also concussion of the spi- 
nal marrow, which is the only circumstance rendering 
the accident important, for the mere fracture of the ver- 
tebral would heal as readily as that of any other bone. A 
palsy of all those parts which derive tlieir nerves from 
below the fractured spot is the immediate consequence 
of every fracture of the spine which produces compres- 
sion on the spinal marrow, whether this be by the pres- 
sure of bone or effused fluids. When this happens, 
therefore, in either of the three superior cervical verte- 
brae, immediate death ensues, from palsy of the fourth 
and fifth pair of cervical nerves, which chiefly supply 
the diaphragm, and which originate in the spinal mar- 
row, a little higher than the place of their exit. Although 
death does not instantaneously follow the fracture of the 
fourth cervical vertebra, yet it very soon occurs.* 

" The variety of causes which may give rise to symp. 
toms analogous to those of fracture of the vertebr* ren- 

• A very rcmarlcablc case occurred in January 1816, wl.ich seems to form 
an cxcept.on to thisgeneral rulc-a gentleman was sliot by apistol presented 
close to h.3 face-the ball entered his nrioutli and shattered the atlas vertebra 
notwithstanding which he survived the accident three weeks, and no symptoms 
of paralysis occurred, though the pus and the ball were in contact with the 
dura mater. 



136 ELEMENTS OF SURGERY. 

der it difficult to establish a diagnosis. Yet when a per- 
son has fallen on his back from an elevated situation, or 
when a body very forcibly impelled, as a bullet dis- 
charged from a musket, has struck that part, if a fracture 
has taken place, some derangement of the spinal process 
of the fractured vertebrse may be observejl, by an atten- 
tive examination of the part affected. Much pain is 
caused by pressing on that process ; the inferior extremi- 
ties are paralyzed, as also the rectum and bladder; the 
patient is afflicted with a retention of urine and faeces, or 
with an involuntary discharge of the latter. 

" This paralysis of the inferior extremities, the neces- 
sary concomitant of the fracture of the vertebrse is not ia 
itself a mortal affection; but the patient losing the power 
of locomotion, and being obliged to lie perpetually on his 
back, soon feels a troublesome itching in the region of 
the sacrum on which the pressure of the body is princi- 
pally concentrated. The skin of this part becomes in- 
flamed and gangrene to a greater or less degree ensues, 
because the pressure on that part intercepts the course of 
the humours. The bone is quickly denuded, the ulcer 
extends rapidly and consumes the patient's strength, the 
dissolution is accelerated by the retention of excrements, 
from the paralysis of the rectum and bladder. The ca- 
theter which must be introduced into this latter organ for 
the purpose of evacuating the urine gives admission to 
the air.''^* ^'^Its mucus secretion becomes more abundant 
and its substance thickened. A slimy matter flows out 
with the urine, and the penis and scrotum become (Ede- 
matous, a slow fever succeeds these symptoms, and the 
patient however robust he may be, falls in a few weeks. 

» The inflammation thus occasioned, is probably not excited, as Mr. Boyer 
supposes, by the admission of air, since there is no reason for supposing this 
fluid a powerful irritant, except when it produces fermentation, in the contents 
of a cavity. 



ELEMENTS OF SURGERY. .^3*^ 

We have known, however, a man of very vigorous con- 
stitution to have survived for six months an accident of 
this nature. Examples of recovery are recorded, but 
they are extremely rare, and to be ascribed to the secret 
operations of nature rather than to the efforts of art, and 
we repeat that scarcely one in thirty recovers ; almost all 
die from the exhaustion of their strength, by slow fever, 
colliquative diarrhoea, &c. 

" Any attempt at setting these fractures would be not 
only useless but dangerous, by the straining which it 
would occasion. General treatment alone can be had 
recourse to.^' (Boyer.) 

In all cases of injury of the spine it is of extreme im- 
portance to introduce a catheter into the bladder, and 
to leave it in with a cork in the orifice, or to introduce it 
and evacuate the urine three or four times every twenty- 
four hours. As the patient in these cases feels no pain 
and is not conscious of the distention of his bladder, it is 
necessary for the surgeon to be aware of the importance 
of attending to this circumstance. A patient was brought 
into the Pennsylvania hospital in the summer of 1812, 
who had been wounded in the spine, by a musket-ball 
two weeks before in a naval engagement. He had re- 
ceived very little attention after the accident ; immediate- 
ly on his admission I ordered the catheter to be intro- 
duced, when nearly three quarts of urine were drawn off; 
he had voided none for two weeks. 

It has been recommended to trepan the spine in cases 
of paralysis from fracture, and to remove the depressed 
bone or effused fluids, as in cases of fractured cranium. 
This operation could not be performed without extreme 
difficulty, and the greatest uncertainty of relieving the 
compression. The inflammation likely to follow the ope- 
ration, would probably occasion a repetition of the pres- 
sure from distention of the vessels within the spinal cavity. 

VOL. I. 19 



138 ELBlNffiNTS OF SURGERY. 

Dr. Physick has attempted to relieve the effects of 
fractures of tlie vertehrae, by makiag extension and coun- 
ter-extension from the head and feet of the patient, the 
head being secured to the upper and tlie feet to the lower 
part of the bedstead. In the first case in which it was 
used, the fracture was situated in the fifth and sixth cer- 
vical vertebra ; the patient regained after the extension, 
the use of his arms which had been paralytic, but expir- 
ed shortly after, apparently from a collection of mucus 
in the trachea which he was unable to cough up, from 
palsy of the expiratory muscles. Perhaps as some relief 
was in this case experienced the remedy may be worthy 
of trial. *^ 

In examining patients with fractures of the spine it is 
of extreme importance not to turn them on their faces, 
but to conduct the examination whilst they lie on one 
side — suffocation has resulted and instant death from ne- 
glecting this caution. 

* An account of tliis case may be seen in Dr. Hartshonie's edition of Boyer 



ELEMENTS OF SURGERY 139 

CHAPTER XXII. 

Fractures of the Ribs. 

The ribs ia consequence of the elastic cartilages in 
which they terminate, and of the strength derived from 
their arched fprm, are not very often fractured. The 
first rib is very seldom broken, as the shoulder and cla- 
vicle protect it greatly from accidental violence. The 
ribs are most commonly broken by falls from a conside- 
rable height, and sometimes by violent blows. They 
are generally broken near their middle, by a transverse 
fracture; sometimes the fracture is oblique, and inconve- 
niences result from the sharp extremities of the frag- 
ments; sometimes these penetrate the external integu- 
ments, forming a compound fracture, and sometimes they 
pierce the pleura and lung, and thus occasion emphysema. 

The fracture is ascertained by an acute pain in breath- 
ing and l)y careful examination with the hand, and by 
pressing the rib in different parts a crepitus may some- 
times be felt. To assist in the investigation the patient 
should be desired to cough whilst the surgeon's hand is 
kept on the part injured, if any fracture exist the act of 
coughing will generally produce crepitation. 

In many cases, especially in very corpulent subjects, 
there is great difficulty in ascertaining the existence of 
the accident, and in all these cases the dressings should 
be applied as if a rib actually were fractured. 

From the articulation of the ribs to the sternum before, 
and tiie vertebrae behind, no diminution of length can 
take place ; no lateral derangement of the fragments can 
happen, because the intercostal muscles act equally on 
both fragments, and tie them to the uninjured ribs above 



140 ELEMENTS OF SURGERY. 

and below. The only derangement which can happen, 
is by an angular projection internally at the place of 
fracture. 

The only treatment necessary in simple fractures of 
the ribs whether one or several be broken, is to keep the 
parts at rest as much as possible during their reunion, 
and this is done by counteracting in great measure their 
motions in respiration. To eifect this, a bandage six 
inches wide is to be passed repeatedly round the chest 
as tight as the patient can suffer it to be drawn. Its de- 
scent may be prevented by a shoulder-strap. When this 
is done respiration is performed, principally by the ac- 
tion of the diaphragm, and the ribs remain, comparative- 
ly at rest. Instead of the roller, a jacket of strong linen 
may be used capable of being laced very tight by means 
of tapes. 

When the lungs have been wounded by a fragment 
of the bone, the patient generally spits blood and coughs 
violently — the lungs inflame, and violent fever comes 
on, attended with difficult respiration and other symp- 
toms of pneumonia. Copious blood-letting, and the usual 
remedies for inflammation must in such cases be em- 
ployed. 

When emphysema occurs from a fractured rib, it is 
to be treated in the same manner as has been recom- 
mended when this affection is consequent to a wound of 
the thorax. If the complaint proceed to any considerable 
extent an incision is to be made into the thorax ; it is, 
however, a very rare occurrence : to prevent it, it has 
been recommended to bind a compress very firmly over 
the fracture. 

When the cartilages of the ribs become ossified, as 
they often do in advanced life, they are also liable to 
fracture, the accident is to be treated just as a broken 
rib. 



ELEMENTS OF SURGERY. ^4£ 

CHAPTER XXIII. 

Fractures of the bones of the Pelvis. 

The OS sacrum is not often fractured — a carriage 
passing over it, or a heavy weight falling on it, may oc- 
casion a fracture: no muscles are inserted into it which 
have any agency in moving the fragments, and the only 
remedy is rest in a horizontal posture. If extensive in- 
flammation result from the contusion accompanying the 
fracture, it is to be treated as usual. If suppuration take 
place, and abscesses form, they must be opened as soon 
as possible, to prevent the formation of fistulous ulcers. 
When large extravasation takes place within the pelvis, 
bleeding and low diet are to be ordered, with a view to 
prevent suppuration, which in this situation would prove 
a very serious evil. 

The OS coccYGis is sometimes broken, though very 
rarely — the existence of this fracture is ascertained by 
pain in the part, and in every attempt to walk this pain 
is augmented : by introducing the finger into the anus, 
the fragments may be felt. The only remedy necessary 
is rest and gentle compression, by means of a compress 
supported by a T bandage. 

The ossA iNNOMiNATA are occasionally broken by a 
variety of accidents ; the fracture occurs in different situa- 
tions. Mr. S. Cooper has seen instances of fracture in 
the ilium, the ischium, and thu os pubis. I have seen 
the acetabulum fractured in such a manner as to occasion 
incurable lameness. The ilium, however, is more fre- 
quently broken than either the ischium or pubis. The 
fracture of these bones, is in itself of less consequence 
ilinn the mischief occasioned by the force which pro- 



14S ELEMENTS OF SURGERY. 

duced it The contents of the pelvis must be contused 
severely by any force great enough to fracture the bones 
which form it, and generally extravasations of blood take 
place into the cellular texture, which intervenes between 
the viscera of the pelvis. 

A fracture of the os innominatum, is to be known by 
the usual symptoms of pain and crepitation upon moving 
the fragments; an inability to walk also occurs, but any 
severe injury to the pelvis produces this : fractures of 
these bones have often been found after death, when their 
existence has been unsuspected. 

The treatment consists chiefly in obviating inflamma- 
tion by the usual remedies, as no displacement of the 
fragments is likely to occur. The inconveniences of dis- 
charging the urine and faeces, are sometimes very great 
in these accidents, but they are much diminished by the 
use of sir James Earle's bed. In some cases suppuration 
takes place, notwithstanding the free use of evacuating 
remedies, and large abscesses form: splinters of bone 
have been found to occasion these collections of matter. 
*^ Desault in giving an exit to a collection of urine which 
had taken place from a fracture of the pelvis, found a 
splinter which he extracted from the bottom of the wound. 
If the bladder be perforated by a splinter, this should be 
extracted, and a catheter introduced, in order to prevent 
the accumulation of urine and its consequent effusion into 
the cavity of the abdomen ;" an accident which has oc- 
curred. 



ELEMENTS OF SURGERY, 14j3 

CHAPTER XXIV. 

Fractures of the Scapula. 

The mass of muscular flesh which sun-ounds the sca- 
pula, and its great mobility, protect it in great measure 
from fracture ; some parts of it, however, are more ex- 
posed than others. The accromion process forms the most 
projecting part of the shoulder, and is oftener fractured 
than any other part of the scapula ; the inferior angle is 
the part next in frequency found broken. The coracoid 
process has seldom been known fractured: a gunshot 
wound, and the falling of a heavy body directly upon it, 
have sometimes, however, occasioned this accident. 

The force which produces the fracture generally occa- 
sions much contusion of the adjacent flesh. When the 
Scapula is broken longitudinally, the muscles on its sur- 
faces prevent a displacement of the fragments, transverse 
fractures are more apt to be accompanied with a derange- 
ment of them. The serratus major anticus muscle, draws 
forward the lower portion to which it is principally at- 
tached. The inequality is evidently perceived by pass- 
ing tlie Angers along the base of the scapula. 

To ascertain the existence of the fracture, it is neces- 
sary to examine particularly whether any derangement 
is evident, and whether any crepitation can be produced 
by pressing the bone in different places. The only frac- 
tures which are not easily discoverable in this way are 
the longitudinal. The lower angle when broken oft' 
moves easily under the fingers, whilst the rest of the 
bone is stationary. 

Wlien the fracture is longitudinal, or transverse 
through the scapula, a roller is to be applied round the 



144 ELEMENTS OF SORGRUY. 

chest and arm, so as to confine the arm close to the side; 
this roller should cover the arm down to the elbow. 

" As the inferior angle when separated by fracture 
from the rest of the bone, is like the condyloid process 
of the jaw, little susceptible of being acted on by any 
means in our power, it will be necessary to act on the 
scapula itself, to push it downwards and forwards, to- 
wards the inferior fragment which the serratus major 
anticus has drawn in that direction. In this case too, 
it is on the arm that it will be necessary to act, in order 
to move the scapula. The arm is to be pushed inward, 
forward, and downward, the fore arm being half bent. 
It must be kept in this position by a circular bandage 
seven yards long. It will be proper at the same time to 
act on the angular detached portion by means of com- 
presses, which may be pressed backward by some rounds 
of a bandage, and thus brought in contact with the rest 
of the bone. The arm may be supported in a sling tied 
on the opposite shoulder.'' (Boyer.) 

" The accromion when fractured is drawn outward 
and downward by the action of the deltoid muscle, at the 
same time that the rest of the bone is drawn upward and 
backward by the trapezius and levator scapulse. This 
fracture is set, by raising the arm in such a manner as 
that the head of the humerus may push upward the ac- 
cromion, which has descended, and which naturally 
covers it like an arched roof, at the same time an assistant 
pushes the scapula forward and downward, in a direc- 
tion opposed to that which is given to the arm" — in 
order that the parts may remain in this situation, band- 
ages are to be applied — " a circular bandage is to be ap> 
plied round the trunk and arm, and afterwards made to 
ascend from the elbow to the shoulder, and vice versa." 
« This bandage like all those of the thorax is very liable 
to be displaced, and therefore to be frequently reapplied, 



ELEMENTS OF SURGERY. -£4,5 

nevei- forgetting on these occasions to have the elbow 
raised and the shoulder pressed down/' (Boyer.) 

Although fractures of the scapula consolidate in the 
ordinary time of thirty-five or forty days, yet in those of 
tlie accroraion it will be necessary to continue the band- 
age a little longer ; not that the generation of callus is 
slower in that part than in any other, but because the 
accromion is acted on by strong muscles, which might 
rupture the callus if exposed to their action before it had 
acquired a great de£;roe of solidity. 



VOL. I. 20 



146 ELEMENTS OF SURGERY. 

CHAPTER XXIV. 

Fractures of the Clavicle. 

The clavicle is perhaps as often broken as any bone 
of the body. Its exposed situation at the upper part of 
the trunk, its long slender shape, and its being covered 
only by the common integuments, expose it to frequent 
accidents. 

The fracture commonly occurs near the middle of the 
bone, as it is here most prominent, it is also occasionally 
broken near the sternal, and humeral extremities. When 
fractured by the falling upon it of a heavy body, the 
nerves of the arm become paralyzed by the contusion. 

In general the fragments are displaced, unless it is 
broken near the shoulder, in which case its firm connex- 
ion by ligaments with the scapula prevent the displace- 
ment. The external fragment, or that nearest the shoul- 
der, is drawn downwards by the weight of the arm, and 
the action of those fibres of the deltoid muscle, which are 
inserted into it, and also by the pectoralis major, which 
when it is depressed draws it forwards, or inwards to- 
wards the sternum ; so that the sternal portion is always 
found riding over the humeral ; the arm of the afl'ected 
side falls over upon the breast, and the patient is unable 
to rotate the humerus, so that it is impossible for him to 
raise his hand upon his head. He leans to the fractured 
side, and the attitude is so remarkable, that the celebrat- 
ed Desault it is said, was never deceived in deciding 
Irom this circumstance alone, the existence of tlie frac- 
ture. Crepitation may easily be produced by moving the 
arm, and the finger passed over the clavicle readily de- 
tects the place of fracture. 



ELEMENTS OF SURGERY, iqjy 

This accident iu itself is not dangerous, but becomes 
so when accompanied with great contusion or laceration 
of the neighbouring soft parts. 

The treatment of this fracture has been the source of 
much difficulty among surgeons, a vast variety of machi- 
nery has been contrived for the purpose of keeping the 
fragments together, and lately a surgeon of great and de- 
served celebrity*^ has renounced all applications and 
trusts to rest in a horizontal posture, as the only neces- 
sary remedy. I refer to Mr. Boyer for a concise account 
of the discarded apparatus of the older surgeons. Mr., 
Desault was the iirst who properly contemplated TOe dif- 
ficulties to be surmounted, and constructed an apparatus^ 
which better than any before in use, removes them. His 
plan with different modifications has been very generally 
used in this country, and continues to be preferred to all 
others, I shall therefore describe it. It is not the smallest 
advantage of his dressings that they are always at hand. 

" The pieces of which this apparatus is composed are, 
1st, Three rollers three inches broad; the two first six, 
the other eight ells long, each one rolled up separately. 

2d, A bolster or pad (Fig. i. a b) made in the form of 
a wedge, out of pieces of old linen. Its length should be 
equal to that of the humerus, its breadth four or five 
inches, and its thickness at the base about three inches. 

3d, Two or three long compresses. 

4<th, A small sling for the arm. 

5th, A piece of linen large enough to cover the whole 
bandage. 

Every thing being properly an-anged, the following is 
the mode of applying the apparatus, which of itself re- 
duces the fracture. 

The patient being placed in a standing position, or if 

* ^Ir. Pclletan, surgeon in chief to the Betel Diext, &c. &c. &c. 



148 ELEMENTS OF SURGEHV. 

his case render that impracticable on a seat without 3 
back, an assistant elevates the arm of the aifected side. 
and supports it at nearly a right angle with the body, 
(Fig. 2.) whilst the surgeon places under the arm-pit the 
head of the bolster, which descends along the side of the 
thorax, and which another assistant situated at the pa- 
tient's sound side holds by two upper corners. 

The surgeon now takes one of the first rollers, applies 
the end of it on the middle of the bolster, fixes it there by 
two circular turns round the body, and passes a turn ob- 
liquely [a a) along the fore part of the thorax ascending 
to th^^ound shoulder. The roller then descends behind, 
passes under the arm, and returning in front of the tho- 
rax, makes a circular turn and a half horizontally. Hav- 
ing reached the hind part of the thorax it reascends ob- 
liquely by the cast [b) as it had done before, and passes 
over, before, and under the sound shoulder; having thus 
crossed the turn (a a) the roller again passes across the 
hind part of the thorax, and finishes by circular turns 
which completely cover the bolster. A pin is now to be 
fixed in the place of crossing of the roller on the sound 
shoulder, to prevent the turn (a) from slipping down- 
ward. 

The application of this first roller is intended for no 
other purpose than firmly to fix the bolster, which is held 
up by the two oblique turns before and behind, and se- 
cured against the body by the subsequent circular turns. 

The bolster being fixed, the surgeon applying one 
hand to its external surface pushes it upwards, and with 
the other, taking hold of the elbow, after having half 
bent the fore arm, lowers the arm till it is laid along the 
bolster. He then presses its lower extremity forcibly 
against the side of the thorax, pushing it upwards at the 
same time and directing its upper extremity a little back- 
wards. 



KLEMEXTS OF SURGERY. I49 

The application of the bandage constitutes a part of 
the process of reduction. The humerus, now converted 
into a lever of the first kind, is drawn at its upper entl 
from the shoulder, in proportion as its lower end is ap- 
proximated to the thorax. The scapulary fragment being 
drawn along with it, and directed at the same time up- 
wards and backward, comes into contact with the sternal 
fragment, and in an instant the deformity of the part dis- 
appears. 

The arm being thus situated is given in charge to an 
assistant, who retains it in the same position in which he 
received it from the surgeon, by pressing on it with one 
hand, and with the other supporting the fore arm half 
bent, and placed horizontally across the breast. 

The second roller is next to be applied. The end of 
this is carried under the arm-pit of the sound side. It is 
then brought across the breast, over the superior part of 
the diseased arm, and extends across the thorax behind 
till it passes under the arm-pit. Two circular turns cover 
the first. The roller must then ascend to the lower part 
of the shoulder by oblique turns (c c Fig. 3.) each of 
which must be overlapped by the succeeding one to the 
extent of about the third part of its breadth. It is ne- 
cessary that these turns be applied in such a way as to 
bind but very gently above, and to increase in tightness, 
as they descend nearer to the lower extremity of the hu- 
merus. 

The use of the second roller is to supply the place of 
the hand of the assistant in pressing the arm against the 
side of the thorax, its effect evidently is to draw the up- 
per extremity of the arm outwards, and as it is already 
directed backwards, to retain it in that position. The 
compression of the circular turns on the arm, beins: thus 
gradually augmented, becomes on the one hand more ef- 
ficacious, because it acts on a greater surface : and on the 



150 ELEMENTS OF SURGERY. 

other less troublesome, because being more divided it is 
less felt at the lower extremity of the arm, where it bears 
with most force. 

A third indication remains to be fulfilled, namely, to 
retain tlie shoulder in its elevated position, and by that 
means to assist in the extension of the fragments, which 
already has some effect in preventing a depression. 

To fulfil this indication, an assistant sustains the 
elbow in its elevated position with one hand, and witli 
the other supports the patient's hand before his breast, 
whilst the surgeon fills with lint the hollow spaces around 
the clavicle. He then applies on the clavicle at the place 
where it is fractured, the two long compresses, wet with 
vegeto mineral water, a solution of sugar of lead, or some 
other cooling liquid. Taking now the last roller, he 
fixes the end of it under the sound shoulder, from thence 
he brings it obliquely across the breast, over the long 
compresses, and carries it down behind the shoulder 
along the posterior part of the arm, till it passes under 
the elbow. From this point he again carries it obliquely 
upwards across the breast to the arm-pit, then across the 
back over the compresses, and brings it down again be- 
fore the shoulder along the front of the humerus, till it 
again reaches the elbow. From thence the roller again 
ascends obliquely behind the thorax, passing under the 
arm-pit where the first coat of the roller is covered, and 
from whence it again starts to run the same course we 
have just described. This constitutes a second round, 
w^hich covei'S in part the first, and forms a kind of double 
triangle, e,/, d, situated before the breast, and over the 
circular turns of the other rollers (c c Fig. 4.) The re- 
maining part of the roller brought from behind forward, 
is employed in circular turns over the arm, and round 
the thorax for the purpose of preventing the displace- 
ment of the first part. To make it the more secure it is 



ELEMENTS OF SURCEEY. 151^ 

fastened with pins or stitches at its different places of 
crossing. 

The sling (Fig. 4.), is next passed under the hand, 
and fastened above to the ascending turns (rf) and not to 
the circular {c c), which the weight of the hand would 
be likely to draw downward. 

It is only necessary to examine the course of this 
third roller to see that united to the sling; it is well cal- 
culated to support the external fragment, which the 
weight of the shoulder, has a tendency to depress on a 
level with the internal one. It supplies the place of the 
assistant wlio raises the elbow, and supports the hand of 
the patient, in like manner as the second roller performs 
the office of the assistant who presses the lower part of 
the humerus against the side of the thorax. 

On the other hand, the circular turns by which the 
application of the third roller is finished, being directed 
from before backwards, push in the same direction the 
arm and shoulder, which have been already carried that 
way, by the process of reduction, and thus retain them 
in tlieir proper places.'' (Desault.) 

By this apparatus the shoulder is kept, upward, back- 
ward, and outward; the weight of the arm and the action 
of the muscles, are thus effectually prevented from draw- 
ins; the lujmeral fragment inward, and downwards. 

'*' Tlie coats of the rollers thus surrounding the tho- 
rax, however well they may be secured, are yet liable to 
be displaced, particularly wlien the patient is in bed. 
This inconvenience may be obviated by surrounding the 
whole with a piece of linen, leaving nothing uncovered 
but the sound arm, wiiich is at liberty to perform its 
usual motions." 

It is better, however, to add to the firmness of the 
dressings by connecting them together with several rows 
of stitches in different places. 



152 ELEMENTS Of SURGEIIY. 

This mode of treating fractured clavicle has been found 
extremely successful, but it has its inconveniences; the 
principal one that I have experienced in its use, is the 
numbness of the arm, and stoppage of the circulation, 
which occur in consequence of the pressure of the bolster 
in the axilla, upon the vessels and nerves of the arm. 
Great attention is necessary to obviate this by diminish- 
ing when it occurs, the tightness of the bandage, which 
passes round the arm near the elbow ; to judge whether 
the pressure be too great, the pulsations of the radial 
artery at the wrist should be attended to ; if they be in- 
terrupted the bandage must be loosened. Another incon- 
venience results from the slipping down of the pad in the 
axilla ; I have in some cases, with advantage, attached 
a piece of tape to it, and tied this on the opposite shoul- 
der. Whenever the dressings become slack they must 
be tightened ; without attending to this circumstance they 
are useless. 

Mr. Boyer, availing himself of the principles of De- 
sault, has constructed a very simple apparatus which acts 
in the same manner, and is very easily applied. 

It consists of a girdle of linen cloth quilted, and six 
inches broad, which passes round the trunk on a level 
with the elbow. It is. fixed on by three straps, and as 
many buckles fastened to its extremities. At an equal 
distance from its extremities, on each side, are placed 
two buckles, that is, two anterior, antl two posterior to 
the arm. A bracelet of quilted linen cloth five or six fin- 
gers broad, is placed on the lower part of the arm of the 
side affected, and laced on the outside of the arm ; four 
straps fixed to this bracelet, that is, two behind and two 
before, correspond to the buckles on the outside of the 
girdle already described, and answer the purpose of 
drawing the lower part of the arm close to the trunk, the 
more so, as the straps by being two before, and two be- 



I Pi^-2. 




Fi^.4. 



ELEMENTS OF SURGERY. igo 

hind, prevent the arm from moving either backwards or 
forwards. With this apparatus, as well as the preceding, 
the cushion must be applied under the arm. 

I have never seen this plan used, but have no doubt it 
would answer veiy well. It cannot, however, be free 
from those inconveniences of Desault's which result from 
pressure in the axilla, and the weight of the arm, appears 
to be less completely supported. 

In about four or iive weeks the fracture will generally 
unite, and no particular attention is necessary to diet or 
regimen; the patient may be allowed to walk about dur- 
ing the cure. 



VOL. r. 2i 



154) ELEMENTS OF SUllGEllY. 

CHAPTER XXVI. 

Fractures of the Os Humeri, 

The OS humeri is fractured most frequently near its 
middle ; occasionally, however, in all its parts. 1 Lave 
known it fractured in one case within the capsular liga- 
ment, the fracture extending through the head of the 
bone. Fractures above the insertion of the pectoral and 
latissimus dorsi muscles, are called fractures of the neck 
of the bone. The lower extremity is also broken, and ia 
some instances the condyles are detached from the rest 
of the bone, and from each other. 

When the fracture is transverse, and is situated near 
the middle of the bone, no great derangement takes place, 
the fragments supporting each other, and the limb pre- 
serving its length, and unless moved, its form. In ob- 
lique fractures, the limb is shortened by the action of the 
muscles, and considerable alteration in its shape is per- 
ceived. 

When the bone is fractured at its upper end, or neck, 
there is some difficulty in distinguishing the accident from 
a dislocation of the head of the bone into the axilla. It 
can always, however, be known, by a depression at the 
upper and external side of the arm, very different from 
that depression which occurs in dislocations, and which 
is situated immediately under the accromion scapulae. In 
the present instance, the shoulder retains its natural ro- 
tundity, and no depression exists directly under the ac- 
cromion. The axilla being examined with the fingers, 
the fractured unequal surface is readily felt; whereas, in 
dislocations, the round head of the bone is felt high up 
in the arm-pit. By moving the arm the grating of the 



ELEMENTS OF SURGERY. 155 

fractured surfaces can be distinctly perceived. The best 
manner of treating this accident, is that described by 
Desault. 

^^ The patient is to be seated on a chair, or on the side 
of a bed, the arm is slightly separated from the body and 
carried a little forward. One assistant is directed to fix 
and secure the trunk in a proper manner; this he does 
by pulling the arm of the sound side, taking hold of it 
near to the hand, and extending it in a direction perpen- 
dicular to the axis of the body. This mode of counter- 
extension, is preferable to that commonly employed, 
which consists in applying the hands to the upper part 
of the patient's shoulder ; because on the one hand, the 
power being further removed from the resisting force 
need not be so great, and on the other, the body being 
entirely unincumbered renders it easy for the surgeon to 
apply the roller, w ithout discontinuing, or in any way 
disturbing the extension. Another assistant makes ex- 
tension on the fore arm, which serves him as a lever, 
where one hand being placed behind, or on the back of 
the wrist, forms the point of support, or fulcrum, while 
the other applied to the anterior and middle part of the 
fore arm, on which it makes pressure from above down- 
ward, constitutes the power^ and the fragments to be 
brought into contact, the resistance. 

Tiie relaxation of the muscles produced by this semi- 
flexi(m of the fore arm, and the separation of the arm 
from the trunk, greatly favours this mode of extension; 
a mode, recommended by the ancients, adhered to by the 
English, and which possesses the advantage of leaving 
uncovered all that portion of the limb on which the ap- 
paratus is to be applied, and by that means of allowing 
the hands of the assistant to keep the same position dur- 
ing the whole time of the application. A small degree 
of force directed according as the displacement is inward 



156 ELEMENTS OF SURGERY. 

or outward, is sufficient to effect the reduction, which 
even takes place of its own accord under this process. 
If the surgeon lays his hands on the place of fracture, 
it is rather to examine the state of the fragments, than to 
assist in bringing them into apposition." 

In order to keep the parts in this state of reduction, 
the surgeon takes a roller, fixes one end of it by two cir- 
cular turns, on the upper part of the fore arm, and carries 
it up along the arm by oblique turns moderately tight, 
and overlapping each other about two thirds of their 
breadth. Having reached the upper part of the limb, he 
makes some reversed turns to prevent the wrinkles, 
which would otherwise be caused by the unevenness at 
this place. He then passes two casts of the roller under 
the opposite arm-pit, and brings it to the top of the 
shoulder again ; a splint* is then placed before, which 
reaches from the fold of the arm to a level with the ac- 
cromion; another on the outside reaching from the ex- 
ternal condyle to the same level ; a third reaching from the 
olecranon to the fold of the arm-pit. f These splints are 
to be secured in their situation by the roller brought down 
over them and secured at the elbow. A bolster is now 
applied between the arm and side; Desault advises this 
bolster ^^ to be made of linen from three to four inches 
thick at one end, tapering like a wedge to the other, and 
of a sufficient length to reach from the arm-pit to the el- 
bow." If the displacement be in an inward direction, 
the thick end is to be placed uppermost, and if outward, 
which is commonly the case, the thin end. This bolster 
is to be pinned to the roller, and the arm then secured 
against it, by a roller passed round the arm and body, 
(as in cases of fractured clavicle), sufficiently tight to 

* Firm pasteboard answers very well for this purpose. 

j- Two splints, each two inches wide, ai-e generally sufficient in this fracture. 



ELEMENTS OP SURGERY. fgy 

keep the arm firmly fixed against the bolster. Instead of 
the cushion or bolster recommended by Desault, com- 
presses of folded flannel or linen maybe substituted, and 
they can be made thicker at one place than another, ac- 
cording as the displacement inward or outward, may re- 
quire. The fore arm is to be suspended in a sling. From 
twenty- six to thirty days are required for the reunion of 
the fragments. It is of consequence in this accident, 
from the vicinity to the joint, to prevent any displace- 
ment of the fragments, as their union under such circum- 
stances would greatly impede the motions of the limb. 
The apparatus just described, which varies in nothing 
important from that of Desault, will effectually prevent 
this inconvenience. 

Fractures occurring in the middle of the bone, or in 
any situation between the immediate vicinity of the el- 
bow and shoulder joints, are very easily dressed. Coun- 
ter-extension is to be made by an assistant with his arms 
round the chest; extension is to be made by anotlier as- 
sistant who draws down the arm, taking hold below the 
elbow. The surgeon readily places the fragments in 
contact, when the arm will be found to have its proper 
length and shape; the external condyle corresponding 
with the most prominent part of the shoulder. A roller 
is now to be applied, extending from the wrist to the 
shoulder (to prevent tumefaction of the fore arm) ; the 
fore arm is to be bent to a right angle with the arm ; when 
the roller reaches the elbow, three or four splints accord- 
ing to the bulk of the arm, (I have never, however, seen 
more than three necessary,) are to be applied to the outer, 
inner, and back part of the arm, and secured by bring- 
ing down the roller over them : these splints should be 
two and a half inches broad, long enough to extend from 
the shoulder to the elbow, the inner one will be several 
inches shorter than the two others, to allow the flexion of 



158 ELEMENTS OF SURCxERY. 

the fore arm, and to prevent excoriation at the axilla. 
They may be made of thin wood, or strips of wood §lued 
upon leather, or tin, or what I have always preferred to 
every other material, thick pasteboard, such as is em- 
ployed for the covers of books. When pasteboard is 
used in this case, it need not be soaked in Avater, but 
bent so as to fit the arm. The roller must never be 
bound so tight as to cause pain. The arm must be sup. 
ported in a sling, and the patient, in general walks about 
during the cure, which is commonly completed in four 
weeks. At the expxration of a week (and in most otlier 
fractures the same thin^ should be done) the dressings 
are to be removed and the part examined, and any dis- 
placement rectified before they are reapplied. 

When the fracture is situated near the condyles, or at 
the condyles, a very different mode of treatment is to be 
adopted. A deformity is extremely apt to occur after this 
accident, and the motion of the elbow is much impeded. 
To obA^iate this, Dr. Physick has for many years been in 
the habit of applying two angular splints, which keep 
the fore arm flexed at a right angle upon the arm. The 
fracture being redaced, and the parts placed in their pro- 
per situation, a roller is to be applied as usual, from the 
wrist to the shoulder, and brouglit down over the angular 
splints : these splints are made of pasteboard or wood, an 
inch and a half wide % the part applied to the arm, ex- 
tends from near the shoulder to the elbow, and the part 
applied to the fore arm, should be long enough to reach 
to the ends of the fingers, to obviate the motions of the 
hand ; a handkerchief passed round the neck, supports 
the weight of the arm. 

After a week has elapsed, the dressings are to be re- 
moved, and the joint carefully and gently flexed, and ex- 
tended several times to prevent stiffness ; after which 
they are to be carefully reapplied, and this is to be re- 



Flats v. 



j-.a 



'%\\ 




■^:. 



^ 



m 



T'A 



^ 






ELEMENTS OF SURGERY. £gg 

peated once in every forty-eight hours, increasing as the 
cure advances, the motion of the joint. At the end of 
three weeks the mode of dressing is to be altered, and 
splints forming an obtuse angle are to be substituted for 
the rectangular,- which had been first employed. The 
object of this change is to prevent a kind of deformity, 
which though not very important in man, as it does not 
interfere with the motions of the joint, is, however, of 
more consequence to females. The deformity alluded to, 
consists, in an angular jjrojection of the elbow, outwards. 
It is most evident when the whole arm is placed at right 
angles to the body, with the tlmmb upwards, the patient 
standing erect. In that case, instead of a gentle curve 
downwards at the elbow, which is natural, the curve is 
directly reversed. I have attempted to represent it in 
the annexed sketch, in which the natural a^d the deform- 
ed appearances, are contrasted. The efi'ect is particu- 
larly apt to occur, when the condyles are broken off 
directly at the joint, and when in addition to this trans- 
verse fracture they are also separated from each other, 
which sometimes happens, from the extreme thinness of 
the bone between the two condyles, occasioned by the 
space for receiving the olecranon behind, and the coronoid 
process of the ulna before. The mode of treatment just 
described, has in several instances, been completely suc- 
cessful in preventing deformity, and preserving tiie per- 
fect motions of the elbow. 

Dr. Physick has since ascertained that the same end 
may be answered by keeping the patient in bed, with the 
arm flexed at the elbow, and lying on its outside, with 
rectangular splints, supported by a pillow. 



150 ELEMENTS OF SURGERY. 

CHAPTER XXVII. 

Fractures of the Fore Arm. 

These are very frequent accidents, and are produced 
by a variety of causes. Sometimes both bones are bro- 
ken, sometimes the radius only, and sometimes the uhia. 
When both bones of the fore arm are fractured^ by the 
same force, the fracture in each bone is generally on the 
same level ; but sometimes one bone is broken higher up 
than the other. The interosseous ligament which connects 
the bones of the fore arm together, generally prevents a 
separation of the fragments in the longitudinal direction ; 
the derangement is most commonly in a transverse direc- 
tion, the four fragments approaching each other at the 
injured part, and a considerable change in the shape of 
the arm is perceived. 

The symptoms of the fracture are very obvious ; great 
pain at the time of the accident, which is augmented by 
every motion of the hand; an inability to pronate or supi- 
nate the hand; mobility at the place of fracture; crepi- 
tus when the fragments are moved, and deformity of the 
member. These symptoms are not so obvious when the 
fracture occurs near the wrist ; the accident has in such 
cases, been mistaken for a dislocation. Boyer mentions 
as the best diagnostic symptom that, when the fracture 
exists, the styloid processes of the radius and ulna fol- 
low the motion of the hand when the wrist is flexed; 
whereas in cases of dislocation they remain fixed. The 
dislocation is a very rare accident, and the fracture a 
very frequent one; in most cases, the crepitus when the 
fragments are moved decides the nature of the injury. 

To reduce the fracture, the fore arm is bent to a right- 



ELEMENTS OF SURGERY. l6l 

angle with the os humeri. An assistant takes firm hold 
of the arm just above the elbow, another grasps the pa- 
tient's hand, and the necessary extension is then made. 
The surgeon very readily adjusts the fragments. 

To dress the fracture a roller is applied, commencing 
at the hand and extending a little above the elbow ; two 
firm splints of pasteboard (not soaked in water), are to be 
next applied ; compresses of linen, flannel, or toW; being 
interposed, to fill up the spaces between the splint and 
arm : the roller being brought down over these splints 
secures them in their situation ; the thumb being upper- 
most may be left projecting out between the splints, as 
an indication that no rotatory motion has displaced the 
fragments. The splints used in dressing all fractures 
of the fore arm, should be long enough to extend from 
the elbow to the extremities of the fingers, and a little 
wider than the broadest part of the arm. They should 
be long, in order to confine the fingers from moving, by 
which irritation would be occasioned, and possibly a dis- 
placement of the fragments, because the muscles moving 
the fingers, are situated on the fore arm ; and they should 
be broad, because the roller passed round narrow splints 
would press the fragments together, and thus by dimin- 
ishing the interosseous space, greatly impede the motions 
of tlie limb : for the same reason the roller first passed 
round the arm should not be drawn tight over the place 
of fracture. The compresses placed on each side of the arm, 
being pressed by the splints upon tlie soft parts situat- 
ed between the bones, force them between tlie two bones 
and thus obviate the inconvenience alluded to : all that 
remains, is to place the arm in a sling. After a week or 
ten days, the dressings should be removed and the part 
examined ; any deviation from the proper position can at 
this period be remedied. In thirty or forty days the cure 
will generally be completed. Whenever the fracture 

VOL. I. 23 



I6a ELEMENTS OF SURGERY. 

occurs near the elbow or wrist, the dressings should be 
removed every forty- eight hours after the tenth day, and 
the joint gently flexed and extended before they are re- 
applied. 

If much contusion be occasioned by the cause of the 
accident, the patient is to be confined to his bed, and the 
inflammation combatted by the usual remedies. 

A compound fracture requires the confinement of the 
arm upon a pillow, and instead of the roller a bandage of 
strips is to be applied (called Scultets, from its inventor 
Scultetus ;) the wound is to be dressed in such a manner 
as to promote its speedy union: if it be small and not 
greatly contused, it may be allowed to scab, and dry lint 
is to be applied over it : if great laceration exist, a poul- 
tice will be found necessary. 

2. When the Radius only, is broken, which is most 
frequently the case in fractures of the fore arm, the mem- 
ber cannot be bent at the place of fracture, as the ulna 
being uninjured, preserves its firmness. The existence 
of the accident is discovered by drawing the hand along 
the edge of the radius firmly, when the fracture can be 
felt by the angle of one of the fragments ; great pain is 
experienced in attempts to rotate the hand, and the cre- 
pitus can generally be heard. When the radius is broken 
near its upper extremity, the depth of muscle in which it 
is imbedded, renders the diagnosis more difficult. In 
these cases Mr. Boyer recommends that '^ the thumb be 
placed under the external condyle of the os humeri, and 
on the superior extremity of the radius, and at the same 
time, the hand is to be brought to the prone and supine 
positions. If in these trials, always painful, the head of 
the bone rests motionless, there can be no doubt of its 
being fractured." There can be no derangement of the 
fragments in fractures of the radius, except what the 
muscles occasion by drawing one or both fragments to- 



ELEMENTS OF SURGERY. ^gg 

wards the ulna; and the pronators principally effect 
this. 

The treatment of this accident is similar to that recom- 
mended when both bones are broken ; the ulna, however, 
acts as a splint in the present case, and aids in keeping 
the fragments at rest; but it has no effect in preventing 
their lateral displacement, and therefore compresses 
must be applied between the splints and the fore arm, to 
keep up pressure upon the interosseous muscles, and 
thereby preclude the approximation of the fragments, to 
the ulna. 

3. When the ulna is alone broken, the fracture is easi- 
ly discovered by passing the hand along it, as it is su- 
perficial, and easily felt from the olecranon to the wrist. 
The treatment is the same as in fracture of both bones, 
unless the fracture happens high up, near the joint. 

When the olecranon is fractured, no difficulty is expe- 
rienced in detecting it. The fracture is generally trans- 
verse, and as the triceps extensor cubiti, is inserted into 
it, the upper fragment is generally separated consider- 
ably from the lower, and the patient loses the power of 
extending the fore arm : a wide space is generally felt 
and seen between the fragments, and they readily move 
upon each other producing crepitus. The proper treat- 
ment of the accident is well described by Boyer. ^^ The 
divided parts, are brought into contact by extending 
the fore arm, and pushing down the olecranon from the 
place to which it had been drawn up by the action of the 
triceps. The principal object is to counteract the action 
of this muscle, which tends incessantly to separate the 
detached olecranon from the ulna. To effect this pur- 
pose, a circular bandage moderately broad, is passed on 
the fore arm fully extended, this being done the olecra- 
non is pushed down into contact with the ulna, and the 
middle part of a long compress placed behind it, the ex- 



164 ELEMENTS OF SURGERY. 

tiemities of which are brought downward, and crossed on 
the anterior part of the fore arm, after which several turns 
of the bandage made so as to cross one another, are car- 
ried round the articulation of the elbow; the bandage 
should then be rolled up on the humerus, in order to 
diminish by pressure the irritability of the triceps, which 
is relaxed by extension of the fore arm. This bandage 
being applied, the bend of the fore arm is filled with lint, 
and a long splint applied on it anteriorly, by which tlie 
flexion of the arm is prevented. The splint is fixed by 
the same bandage, rolled on downward from the shoulder 
to the wrist. The oblique casts of the roller which cross 
one another on the articulation, forming a kind of figure 
of 8, ought to be nicely applied and drawn very tight; 
because if but slightly braced, their action, which is ob- 
lique, will not be sufficient to confine the olecranon in its 
situation. Previous to the application of these oblique 
casts, the skin of the olecranon should be drawn up by 
an assistant, for if this precaution be not taken, it may 
sink between the divided portions and prevent tlieir con- 
tact. 

Though the contact be exact, immediately after the 
application of the bandage, yet if, as is apt to happen, 
the bandage become relaxed, or if the patient inadver- 
tently contract the triceps, the olecranon ascends ; be- 
cause the bandage acting perpendicularly to its direction, 
can but feebly oppose the ascent of this process : an in- 
terval will therefore exist between the ulna, and olecra- 
non, which will be filled up by granulations, and by the 
thickening of the periosteum, or tendinous expansion of 
triceps wliich covers that bone, and the reunion of the 
parts will be effected by means of an intermediate liga- 
mentous substance, the length of which will depend on 
the careful application, and frequent renewal of the band- 
age. In forty or forty-five days the ligamentous sub- 



ELEMENTS OF SURGERY. ^gg 

stance acquires its greatest consistence, but the articula- 
tion should not be kept motionless so long ; gentle mo- 
tion may be commenced on the twenty-fifth or thirtieth 
day. The object of these motions is to prevent a false 
anchylosis of the articulation. 

In cases of recovery obtained by these means, the ole- 
cranon adheres to the ulna firmly enough to transmit to 
it the action of the triceps muscle, and to moderate the 
extension of the fore arm. 

Compound fracture of the olecranon is an accident 
of the most grievous nature, on account of the great 
number of nerves which pass in the neighbourhood of 
that part. It should therefore be treated with the great- 
est care. The inflammatory symptoms are to be treat- 
ed by copious and repeated bleedings; the arm is to 
be placed half bent on a pillow and dressed with Scul- 
tets bandage. In these cases the intermediate ligamen- 
tous substance is always greater than in simple frac- 
ture, and consequently the force of the arm is much di- 
minished. If a false anchylosis be prevented by judi- 
ciously exercising the articulation as soon as the state 
of the parts will permit, the patient may think himself 
fortunate. 

If the inflammatory swelling, &c., be not dissipated 
before the twenty-fifth or twenty-sixth day, the appli- 
cation of the apparatus we have just described will be 
useless, because it will be necessary at that time to be- 
gin to exercise the articulation, the formation of the li- 
gamentous substance being then considerably advanced." 

(BOYER.) 

The coronoid process of the ulna, Dr. Physick has 
once seen broken. The symptoms resembled a disloca- 
tion of the humerus forward, or rather a luxation of the 
fore arm backward, except that when the reduction was 
nflected, the dislocation was repeated, and by careful 



166 ELE\tENTS OF SURGERY. 

examination, the crepitation was discovered. The fore 
arm was kept flexed at a right angle with the humerus. 
The tendency of the brachieus internus to draw up the 
superior fragment, was counteracted in some measure, 
by the pressure of the roller above the elbow. A perfect 
cure was readily obtained. 



ELEMENTS OF SURGERY. >^6y 

CHAPTER XXVin. 

Fractures of the Wrist and Hand. 

Fractures of the bones of the carpus very rarely occur, 
except in gunshot wounds, or by a heavy body falling 
upon them. In every case of this accident which I have 
seen, the fracture has been an object of secondary import- 
ance, and amputation has in general been necessary from 
the nature of the injury. Where the limb is to be pre- 
served, the hand is to be placed in a straight position 
and kept at rest by splints and bandages. 

The bones of the metacarpus are sometimes broken. I 
have known them fractured in pugilistic contests. The 
accident is readily known from the crepitation perceived 
at the place of fracture by careful examination. The treat- 
ment consists in filling the palm of the hand with a com- 
press, and applying a straight splint in front, extending 
from just below the elbow to the ends of the fingers. 

The bones of the fingers are also sometimes broken. 
All the different phalanges are liable to fracture. The 
accident is known by the change of shape in the finger, 
and by the motion at the fractured part, which is attend- 
ed with evident crepitation. The reduction is easily ef- 
fected, and is to be maintained by a narrow roller passed 
round the finger, and by two firm pasteboard splints, one 
before, and one behind wider than the finger and bent a 
little round it, which are to be secured by the same rol- 
ler. I have found it useful to prevent the motion of the 
fingers and hand by a firm splint, long enough to reach 
from the middle of the fore arm to the finger ends. In 
about four weeks the union is generally completed. 

" When a very heavy body lias crushed the extremi- 



168 ELEMENTS OP SURGERY. 

ties of the fingers, or when they have been bruised by a 
folding door, the soft parts are generally lacerated, the 
nail torn off, and the last phalanx fractured and dcnu- 
dated. If in such cases, the parts hold together by a 
shred of a certain thickness, and which contains vessels 
enough for the nourishment of the phalanx, the reunion 
of the parts should be attempted. The prospect of suc- 
cess it is true, is not great in most cases, but if onr en- 
deavours to save the finger fail, amputation is still as 
much in our power, as in the commencement. 

" If the last phalanx alone is crushed, it will be better 
to, amputate at once, than attempt to save the joint. Tire 
cure would be difficult and tedious, on account of the ex- 
foliation that would take place. Besides the part being 
deformed, instead of being useful, would be troublesome. 
By amputating at the articulation with the second pha- 
lanx, a simple wound is substituted to the ragged and 
lacerated wound, produced by the cause of fracture. 
This will heal in a very short time, if care be taken to 
preserve a sufficiency of skin to cover the surface of thf 
articulation." (Boyer.) 



FXEMENTS OP SURGERY. ^Qg 

CHAPTER XXIX. 

Fractures of the Thigh. 

The OS femoris is very frequently broken, and it is of 
great importance to treat tlie accident in such a manner 
as to prevent deformity and lameness, which are oftepi 
its consequences. 

The thigh bone may be broken at the head, even with- 
in the acetabulum; at the neck, at the condyles, and at 
any part between the neck and condyles. The great 
trochanter is in some cases, knocked off from the rest of 
the bone. The fracture is sometimes transverse^ some- 
times oblique, sometimes comminuted^ sometimes com- 
pound ; but most commonly we find it, a simple oblique 
fracture. 

A fracture of the os femoris is attended with a mobility 
at the fractured part, an inability to stand on the limb, or 
to move it without extreme pain at the fracture ; generally 
with a very distinct crepitation when the fragments are 
moved against each other, and almost in every instance 
with deformity and shortening of the member. 

Mr. Boyer observes, that " the numerous muscles of 
the tiiigh by means of which derangement may be effect- 
ed, are divisible into three classes, relative to the man- 
ner in which they tend to effect it. The three portions of 
the triceps femoiis are attached to both pieces, and tend 
to produce the angular derangement by drawing the two 
fractured portions to a salient angle on the outside, where 
their fibres are strongest and most numerous. The biceps 
femoris, semitendinosus, semimembranosus, sartorius, 
rectus internus, and third adductor, ail those in short. 



lyO ELEMENTS OF SURGERY. 

which extend from the pelvis to the inferior portion, oi 
to the leg with which it articulates, tend to draw the in- 
ferior portion upward, on the internal side of the supe- 
rior, the extremity of which forms a tumour on the exter- 
nal side of the thigh. The inferior portion is that which 
is always displaced, except when the fracture takes place 
immediately under the small trochanter, to which process 
are attached, by a common insertion, the psoas and iliacus 
muscles ; which muscles would, in such a case, draw the 
superior portion upward and forward, producing by that 
means a tumour in the groin. 

When the femur is fractured immediately above the 
condyles, the inferior piece is drawn backward, and its 
superior surface turned downward by the action of the 
gastrocnemius externus, plantaris, and popliteus muscles. 
When the great trochanter is detached from the rest of 
the bone, it is drawn upward by the miiscles which are 
inserted into it, but without producing any change in the 
direction or form of the thigh. 

The angular derangement in which the foot inclines, 
either inward or outward, is the effect of the weight of the 
foot or of the bed-clothes, rather than of muscular con- 
traction." 

Transverse fractures are less liable to displacement, 
and are more easily retained in their natural position 
than oblique, for very obvious reasons, the opposing sur- 
faces supporting each other to a certain extent. 

Fractures of the os femoris are more difficult of cure 
than those of any other limb ; and such was formerly the 
want of success in preventing deformity that the ancients 
considered it impossible to cure them without shortening 
of the thigh, and Mr. John Bell, notwithstanding his high 
notions of modern surgery declares, that <^ the machine is 
not yet invented, by which a fractured thigh bone can be 



ELEMENTS OF SURGERY. >£iv.^ 

perfectly secured." A position which, though entirely 
false, proves that surgeons consider the fracture of a very 
serious nature. 

Before proceeding to detail the practice 1 wish to re- 
commend in the treatment of fractures' of the os femoris, 
It may not he amiss to premise, that surgeons have heen 
greatly divided in their opinions respecting the posture in 
which the patient should be placed during the cure. 

The celebrated Mr. Percival Pott, was a warm advo- 
cate for a bent position, and recommended the thigh to be 
bent upon the pelvis, and the leg upon the thigh, and the 
patient to be laid upon his side, under an idea, that in this 
manner the muscles would be most completely relaxed, and 
thus the great cause of deformity obviated. The British 
surgeons have pretty generally followed this practice. 

The late French writers, and particularly Desault and 
Boyer, have strenuously recommended a contrary prac- 
tice, placing the patient on the back and extending the 
lower extremity ; the reasons which induced them to re- 
ject Mr. Pott's plan, Desault states to be ^^ the difficulty 
of making extension and counter- extension, with the 
limb thus situated ; the necessity of making them on tlie 
fractured bone itself, and not on a part remote from the 
fracture, such as the lower part of the leg; the impossi- 
bility of comparing the broken with the sound limb; the 
uneasiness occasioned by this position if long continued, 
though at first it may appear most natural ; the trouble- 
some and painful pressure on the great trochanter of the 
aflected side; the derangements to which the fragments are 
exposed when the patient goes to stool ; the difficulty of 
fixing the leg with sufficient steadiness, to prevent it from 
affecting the os femoris by its motions; the evident im- 
practicability of this method ivhen both thighs are broken, 
atid finally experience, which in France has been by no 
means favourable to the position recommended by Pott," 



X7S ELEMENTS OF SURGERY. 

Mr. John Bell, with all that copia verborum which 
characterizes his truly peculiar style, and with all that 
violence, with which he opposes every thing he fancies 
wrong, has devoted several quarto pages of his Princi- 
ples of Surgery to an abusive opposition of the practice 
of Desault, whose theory he pronounces " unworthy his 
high character," and asserts that " his intentions, and ia- 
deed his very words, are anticipated not merely by old 
surgeons whose works he might have neglected to read, 
but by his immediate predecessors and cotemporaries, 
Petit, Sabatier, and Duverney." Mr. Bell declares, 
that Desault's plan " is neither original nor successful," 
and that " the napkin round the thorax produces oppres- 
sion and insufferable distress which no one can possibly 
bear." Mr. Bell in this and many other passages proves 
incontestibly that he never saw Desault's apparatus ap- 
plied ; that he is entirely ignorant of it, and that in this, 
as in several other instances, he writes and rails on a sub- 
ject he does not comprehend. In proof of this, I shall 
quote the following passage, which strongly evinces his 
want of candour, and his want of correct information. 

'' To judge of the merits of these methods, imagine to 
yourselves the condition of a patient under Desault's dis- 
cipline ; first laid down on one side and bound to the long 
splint of Duverney that the body and the limb were as one 
piece ; next a great napkin put round the thorax with all 
the firmness of a bandage ; straps going round the thorax, 
passing under the arm-pits fixed to this circular, and the 
patient drawn up by these straps to the head of the bed. 
Next imagine, two lacs or long bandages, fixed one round 
the knee the other round the ankle, one tightened when 
the other had caused excoriation ; imagine the patient, 
extended like a malefactor drawn by horses, bound so 
down to the bed, that even a cloth or flat dish could not 
be slipped in undor him; the bands assiduously tightened 



ELEMENTS OF SURGERY. ^yg 

the moment they seemed to relax, and the thorax so bound 
and compressed that he could not breathe ; think of all this 
apparatus of bandage if you can, without holding in your 
breath, as if trying whether such oppression could be en- 
dured. I think for my share, I could as well undertake 
to live under water, as in Desault's, I might say Damien's 
bed." When the reader has finished this rhapsody, let 
him imagine something precisely opposite to what Mr. 
Bell has imagined, and he will have some idea of De- 
sault's apparatus. 

How far Desault or Damien, are to be considered as 
authors of this imaginary apparatus of Mr. Bell, a peru- 
sal of their writings will show ; but it is truly astonishing 
that after such gross perversions, Mr. Bell should have 
the effrontery to add, that he has quoted his histories of 
the various machines " in the very words of the inven- 
tors, because it is the only fair and impartial representa- 
tion."* Mr. Bell knew what would have been impartial ; 
and yet far from quoting Desault's ^^ very words/' his 
whole object has been to misrepresent them. 

I should owe an apology for this digression if the ob- 
ject were less important, but I am solicitous that students 
of surgery should not consider the sophistries of Mr. 
John Bell as logical arguments. 

I should next proceed to state the advantages of the 
straight position in fractured thigh, but having quoted 
them from Desault, I shall simply detail the mode of 
treatment which I consider best adapted to the accident, 
and which is a modification of that proposed by Desault, 
just premising that although volumes have been written 
on the action of the muscles in occasioning derangements 
of the fragments, it is a certain truth which has been too 
much overlooked by all writers, that the muscles very 

* John Bell— Principles of Siir(yer}', Vol. T. 



174 ELEMENTS OF SURGER\ 

speedily accommodate themselves to any posture, and 
that therefore, that one should be chosen, which is most 
favourable to the healing of the fracture and the conve- 
nience of the patient, and this for many reasons which I 
shall not detail in this place (but the chief of which is 
the experience of the surgeons in the Pennsylvania hos- 
pital and in the French hospitals,) I believe to be the 
straight position. 

The bed should be prepared and the dressings dispos- 
ed on it before the patient is placed upon it. If sir James 
Earle's bed, cannot be procured, a hair mattress may be 
placed upon a common bedstead, but boards or strips of 
wood should be substituted for the sacking bottom ; across 
this mattress, five or six pieces of tape should be laid; 
over the tapes a piece of muslin a yard in width, and a 
yard and a half long (if the patient be an adult;) over 
this " splint cloth" a splint of pasteboard nine inches 
long and two wide is to be placed at its upper end, and 
a bandage of strips long enough to extend from the knee 
to the groin, is to be laid over this splint; each strip 
should be of muslin, two inches wide, and long enough 
to pass round the thigh, and overlap several inches. In 
arranging these strips, the one which is to be last applied 
to the thigh, must be the first laid down, and this will be 
the upper one, which should be rather longer than the 
rest, because the thigh is thickest at its upper part; each 
succeeding strip is to cover one-third part or half of that 
which preceded it. The next things to be provided, are 
two bags of chaff, or finely cut straw, four inches wide 
and long enough to extend from the hip to the foot; if 
these cannot be obtained, flannel or tow may be used as 
compresses, in lieu of them. A silk handkerchief, or a 
strong band of soft linen, is to be placed at the top of the 
splint cloth for counter- extension, and a similar one is to 
be provided for making extension at the ankle. Two long 



ELEMENTS OP SURGERY. ly^ 

splints are to be procured, made of light wood ; the first, 
which is that of Desault, improved by Dr. Physick and 
Dr. Hutchinson, sRould be so long as to extend from the 
axilla six inches below the foot; it is formed like a crutch 
at its upper extremity, and a block projects from near its 
lower end, the use of which will be presently noticed ; 
two holes are formed near the upper extremity, and one 
near the lower, through which the counter-extending and 
extending bands are passed; the second long splint is 
three inches wide above, and tapers to two and a half 
below, and long enough to reach from the perineum to the 
end of the longest splint; a fourth splint, of the same di- 
mensions and materials as the first, completes tlie appa- 
ratus. 

The patient is now to be placed carefully on his back 
on the mattress, in such a manner that the injured thigh 
may be situated upon the bandage of strips. The band 
for counter- extension is now passed along the perineum, 
and between the scrotum (or labium pudendi) and the 
afl'ected tliigh, and is delivered to an assistant. The banj 
for extension is passed round the ankle, tied under the 
foot and delivered to another assistant ; by pulling these 
bands extension is made, and the surgeon replaces care- 
fully the fragments in apposition, and then applies the 
bandage of strips, beginning at the knee and proceeding 
upward to the groin. The two long splints are now fold- 
ed up in the splint cloth so that both splints may apply 
neatly to the sides of the limb ; the bags of chaft', or com- 
presses are interposed to till up the spaces occasioned b}- 
the inequalities of the leg and thigh, and the two extremi- 
ties of the bands for counter-extension are passed through 
the two holes near the upper end of the splint and tied 
firmly ; care being taken not to permit the displacement 
of tlie fragments whilst this is done. The band for ex- 
tension is next passed through the hole at the lower end 



176 ELEMENTS OF SURGEftY. 

of the splint, and tied ; but great caution is to l>e used 
in this stage of the business, to avoid, on the one hand, 
drawing tlie bandage too tight, and on the other, relax- 
ing it so as to suffer the fragments to pass eacli other. 
All that now remains is to apply the fourth splint on 
top of the thigh, and secure it by three tapes, which will 
bind all four of the splints moderately tight upon the 
thigh, and to secure the lower extremities of the two long 
splints by two or three tapes between the knee and ankle. 
A bandage or handkerchief may now be passed round 
the pelvis, to assist in fixing the patient at rest, and this 
bandage will certainly be found to exert no mischievous 
effects on the organs of respiration. 

The use of the posterior pasteboard splint, is chiefly to 
prevent the tape passed round the thigh from irritating 
the skin, and also to assist in gently compressing the 
muscles of the thigh and supporting equably the frag- 
ments of the bone behind. 

The principal difference between the mode of dressing 
a fractured thigh, just described, and that recommended 
by Desault, consists in the increased length of the splint 
by which the permanent extension is kept up ; an im- 
provement which was first made by Dr. Physick. 

In the first of the annexed engravings, Desault's appa- 
ratus is represented, and in the second the improvements 
that have been introduced by Dr. Physick, which cer- 
tainly give to the apparatus some important advantages. 
In the first place, the splint of Desault being but little 
longer than the limb, the strap or band for counter-ex- 
tension passes over the upper part of the os femoris at 
an oblique angle, and has a strong tendency to draw the 
superior fragment of the bone outwards; whereas in the 
splint contrived by Dr. Physick, the mortise hole being 
cut high up near the axilla, the band for counter-exten- 
sion acts upon the pelvis, in a line nearly parallel with 



ELEMENTS OF SURGERY. ^yy 

the natural direction of the limb, and has no tendency to 
any lateral displacement of either fragment. In the next 
place, by extending the splint as high as the axilla, the 
pressure of the end of the splint does not injure the pa- 
tient's hip. The crutch-like form is intended to prevent 
the extremity from rubbing against the patient's side, and 
it is to be covered with soft flannel or linen, to defend 
the axilla. 

Dr. Physick having in some cases found that when 
considerable force was applied to the extending band, the 
foot was pulled outward and pressed against the splint 
so as to occasion excoriation, and finding the use of com- 
presses and the chaft' bags inefficient in preventing this 
inconvenience, suggested to Dr. Hutchinson, tlien a stu- 
dent at the Pennsylvania hospital, the advantage of some 
contrivance to obviate it. He accordingly attached to the 
lower end of the splint a block, projecting two or three 
inches from the inside of the splint, across which the 
band for extension is carried to the mortise hole at the 
h)wer end of the splint. The splint being thus construct- 
ed, the extension is also made more completely in the 
direction of the limb. 

By the use of this apparatus there can be no doubt 
that »* permanent extension" of the thigh bone, notwith- 
standing the cavils of Mr. J. Bell, may be kept up, and 
that a perfect cure may in most cases be effected, with- 
out the slightest evident deformity, or shortening of the 
limb. I liave for twelve or fourteen years witnessed the 
effect of this mode of treatment in the Pennsylvania hos- 
pital, where more accidents are admitted than in any 
other institution in America, and I am safe in asserting, 
that the success of the practice has been surpassed by 
that of no otiier hospital in the world. I have never seen 
a crooked limb, or a sliortened limb, the consequence of 
a simple fractiue of the tliigh;, unattended by commiuu- 

VOL. I. 34 



178 ELEMENTS OF SURGERY. 

tion, M'here DesauU's apparatus, modified as above, has 
been fairly applied. 

It is proper, however, to remark, that some practition- 
ers have become dissatisfied with this mode of treatment 
in consequence of the excoriation which they have found 
to take place at the perineum and at the top of the foot. 
In answer to this objection it must be stated, that the use 
of ^^ permanent extension" does not imply violent exten- 
sion, nor sudden extension, but simply a long continued 
resistance to the contraction of muscles which would if 
unresisted, shorten the limb. In order to effect this, after 
the dressings arc applied, it is proper in every instance, if 
any pain is experienced, either at the foot or perineum, 
to loosen the extending band. Most of the inconveniences 
attributed to the method of Desault have arisen from its 
improper application, and nothing is more improper, than 
to make violent extension during the existence of the 
irritation and inflammatory symptoms which succeed to a 
fracture of the os femoris. The extending bandages 
ought always to be very moderately tense, during the 
first three or four days after the accident, and afterwards 
they should be gradually tightened, the limb being exa- 
mined from day to day, and its comparative length with 
its uninjured fellow, distinctly ascertained. If the patient 
experience any difficulty in bearing pressure upon the top 
of the foot, a piece of buckskin with holes in front may 
be laced round the ankle, and straps attached to this 
afford a very convenient substitute for the handkerchief 
with which the extension is made. In warm weather, and 
in emaciated persons this gaiter of buckskin is extremely 
useful. 

By observing these precautions, very little difficulty 
will be experienced in the treatment of fractures of the 
thigh bone near its middle. Six or eight weeks are gene- 
rally necessary for the reunion of a fractured thigh bone. 



ELEMENTS OF SURGERY. |^g 

Compound fractures of the body of the os femoris re- 
quire no difference of treatment from other compound 
fractures, but the dressings necessary for the external 
wound may be very conveniently applied, without inter- 
fering with the long splints. 

When both thighs are broken, or when one thigh is 
fractured in several parts, no plan of treatment is compa- 
rable with that by permanent extension. I have had oc- 
casion to apply it in the case of a miller's wife who was 
caught in some machinery; which fractured both her 
thighs and one leg below the knee. She was placed on 
her back, and the dressings which have been recommend- 
ed, were applied ; she recovered as happily as if only one 
fracture had existed, experiencing very little more pain, 
fever or inconvenience, than is usual in simple fractures 
of the thigh or leg. 

It has been proposed among other methods of preserv- 
ing a bent position, to place the patient on his back with 
an angular box under the knee. I have known this plan 
used, and much difficulty was experienced in preventing 
the rotation of the limb, every motion of the pelvis, occa- 
sioned motion at the fracture, and the surgeon who at- 
tempted it, laid it aside.* 

Fractures of the great trochanter are the effect 
either of falls on that protuberance, or of the action of bo- 
dies striking against it. They are either oblique, or trans- 
verse, situated sometimes at its summit, and sometimes 
at its base. 

This accident may be distinguished, by a facility of 
moving the great trochanter in every direction, while the 
pelvis and the thigh remain without motion; by a crepita- 
tion, arisingfrom the friction of the divided surfaces against 

• Something of this kind has been recommended by Mr. Charles Bell. Ope- 
rative Surgery, Vol. II. page 190. 



180 ELEMENTS OF SURGERY. 

each other; by their being no shortening of the limb, 
when the fracture exists aloue : by the fragments being 
brought together in abduction, and separated in adduc- 
tion ; by the position of the great trochanter being high- 
er and more anterior than natural. The presence of 
these signs are more readily perceived, because, being 
superficially situated, this protuberance can be easily 
felt, and yields to the motions impressed on it. 

The reduction is effected, by pushing the separated 
fragment in the direction opposite to that of its displace- 
ment, by bringing it to its natural level, and, in certain 
cases, by moving the thigh a little outwards; it is retain- 
ed by means of some compresses placed by its sides, and 
secured by a roller directed obliquely from the sound 
hip towards that part of the thigh corresponding to the 
fracture. 

Fractures of the neck of the os femoris are not 
so frequent as those of the body of the bone, but they do 
occasionally occur ; the fracture is generally transverse, 
occurs at every part of the neck of the bone, sometimes 
completely within the capsular ligament, so that the 
round ligament, constitutes the only connexion which 
the upper fragment has with the body. As this accident 
has some symptoms in common with certain dislocations 
of the OS femoris, it is of great importance to discriminate 
this accident from all others. Desault states the follow- 
ing as the best diagnostic symptoms. ^^ At the time of 
the fall a sharp pain is felt, sometimes a noise is distinct- 
ly heard, a sudden inability to move the limb occurs, and 
in general the patient cannot rise, this last circumstance, 
however, is not uniform ; a case is recorded in the fourth 
volume of the Mem. Acad. Surg, where the patient 
walked home after the fall, and even rose up the follow- 
ing day. Desault also saw examples of this peculiarity. 
The interlocking of the fragments is the cause of it. 



ELEMENTS OF SURGERY. |g|^ 

A shortening of the limb almost always occurs, more 
or less perceptible^ according as the extremity of the frag- 
ments are retained by the capsule, or as the division, 
being without the cavity, no resistance is made to their 
displacement. The muscular action drawing the lower 
fragment upwards, and the weight of the trunk, pushing 
the pelvis and superior fragment downward, are the 
causes of this shortening. A slight effort is in general 
sufficient to remove this shortening, which, however, 
soon returns when the effort ceases. A tumefaction ap- 
pears in the anterior and upper part of the thigh, almost 
always proportioned to its shortening, of whicb it ap- 
pears to be the effect. 

The projection of the great trochanter is almost entire- 
ly removed. That protuberance being directed upward 
and backward, is approximated to the spine of the ilium. 
But if it be pushed in the opposite direction, it readily 
yields, and then returning to its proper level, allows the 
patient to move the thigh. 

" The knee is a little bent. A severe pain always ac- 
companies the motions of abduction, when they are com- 
municated to the limb. If, while the hand is applied to 
the great trochanter, the limb be made to rotate on its 
axis, tliis bony protuberance is perceived to turn on itself 
as on a pivot, instead of describing, as it does in its natu- 
ral state, the arch of a circle, of which the neck of the os 
femoris is the radius. This sign, which was first ob- 
served by Desault, is very perceptible, when the fracture 
is at the root of the neck ; less, when it is in tlie middle, 
and very little, when it exists towards the head of the 
bone : tliese are circumstances the cause of which it is 
unnecessary to unfold. In rotatory motions, the lower 
fragment, rubbing against the upper one, produces a dis- 
tinct crepitation, a phenomenon which does not always 
occur. 



18a ELEMENTS OP SURGERY. 

" The point of the foot is usually turned outwards ; a 
position which Sabatier, Bruninghausen, and most other 
practitioners, regard as a necessary effect of the fracture; 
although Ambrose Parey and Petit have borne witness 
that it does not always exist. Two cases, reported on 
this subject, by celebrated surgeons, have been thought 
unfounded by Louis, who has attributed them either to 
an error in language, or a mistake of the transcriber. But 
the practice of Desault has fully confirmed their possi- 
bility. The first patient whom he had under his care, at 
the hospital of Charity, after he was appointed surgeon 
in chief, laboured under a fracture which presented this 
phenomenon. Many other examples occurred to him after- 
wards, and he believed it might be laid down as an estab- 
lished principle, that, in fractures of the neck of the os 
femoris, the direction of the foot outwards is to that in- 
wards as eight to two. 

^^ The common opinion is, that this direction outwards, 
is to be attributed to the muscles that perform rotation. 
But, were that the case, 1st, it is evident that it would 
always exist: 2dly, all the muscles running from the pel- 
vis towards the trochanter, except the quadratus, are in 
a state of relaxation, in consequence of the approximation 
of the OS femoris to their points of insertion : 3dly, mus- 
cles in a state of contraction would not allow the point of 
the foot to be drawn so easily inwards. Is it not more 
probable, that the weight of the part draws it in the direc- 
tion in which it is usually found. 

'* From the foregoing considerations, it follows, that 
none of the signs of a fracture of the neck of the os femo- 
ris, is exclusively characteristic, that the whole of them, 
taken separately, would be insufficient, and that it is their 
assemblage alone, which can throw on the diagnosis that 
light which is oftentimes wanting to it, even in the view 
of able practitioners. But after all, in the present case, 



ELEMENTS OF SURGERY. j^gg 

as in every other one, should any doubt exist, it is right 
to take the safe side, and apply the apparatus, which is 
indeed useless, but not dangerous, if the fracture does not 
exist, but indispensably necessary if it does." (Desault.) 

A concise abstract of the symptoms enumerated by 
Boyer will aid the student in distinguishing this frac- 
ture. A fall or blow on the trochanter or feet, is gene- 
rally the cause ; it is followed by pain in the articulation, 
an impossibility to bend the thigh ; shortness of the limb, 
which is easily removed, but returns when the extension 
is discontinued; an inclination of the foot and knee out- 
ward, with great facility of moving these parts to their 
natural situation; crepitation produced in different move- 
ments ; and the smallness of the circle in which the great 
trochanter moves in a rotatory motion. We can seldom be 
mistaken as to the existence of this fracture, if we attend 
to all these circumstances. 

Of all fractures of the os femoris, those of the neck are 
most tedious in healing, and attended with most danger 
of lameness and deformity. Some surgeons imagine, that 
bony union never forms between the fragments ; but many 
proofs exist that this opinion is erroneous, and prepara- 
tions in different anatomical collections shew instances 
of bony reunion of the neck of the thigh bone. It is al- 
ways, however, slower in its formation, and in many in- 
stances does not at all take place, the patient remaining 
incurably lame. 

Instances of recovery in old persons are not frequent, 
and Boyer considers the fracture ''' after a certain age" 
incurable ; but he adds " it is not in our power to mark 
precisely the period beyond which a cure is not to be 
hoped for. To be able to settle this, it would be neces- 
sary that the effects of old age were uniform in every in- 
dividual, and that the degree of senility were always 
commensurate with the number of years. Lesne shewed 



184 ELEMENTS OF SUUGEBY. 

at the Academy of Surgery, the femur of a woman aged 
eighty-nine, with evident marks of a consolidated frac- 
ture of its neck." Boyer himself, saw a patient in which 
the consolidation of a double fracture was considerably 
advanced in a man eighty-three years old. Numerous 
facts of this nature, authorize and require the application 
of the apparatus in all cases, except where the patient 
reduced to the last stage of decrepitude and debility can- 
not support its weight, or is attacked by some mortal 
disease. But at the same time the surgeon should for his 
own sake, acquaint the patient and his friends with the 
uncertainty of the cure, in order to ward off any imputa- 
tion that might be made in case of failure. 

Many respectable surgeons have positively asserted 
that a recovery without lameness and shortening is im- 
possible. Desault and Boyer on the contrary, both relate 
instances in which they were completely successful. 

The fracture is easily reduced by making counter-ex- 
tension at the arm-pits, an assistant holding the patient 
under the arms, and extension by drawing down the foot 
until the limb resumes its natural length and appearance, 
it is not easy, however, to secure the fragments in con- 
tact, but the apparatus of Desault promises to be more 
successful than any other plan heretofore in use for that 
purpose. The long splints are to be applied precisely 
as in fractures of the body of the os femoris, but no band- 
ages of strips, or pasteboard splints are required in this 
case, as the permanent extension is alone necessary, and 
they would be useless as they would act only on the in- 
ferior fragment. 

The fracture healed in one case recorded by Desault, 
in sixty days, but generally three months are required 
for the consolidation. During this time the apparatus 
should be examined daily, and tightened from time to 
time, if any shortening of the limb is observed. Stiff- 



ELEMENTS OP SURGERY. ^35 

ness of the joint is not a frequent consequence of this 
accident. 

When the permanent extension cannot be applied, 
from the extreme age of the patient, or any other cause, 
great care should be taken to prevent the motions of the 
fragments, by long stiff splints bound firmly on the pel- 
vi:^, and extending below the foot. In this manner a cure 
will be effected, but probably the detached neck of the 
bone M'ill adhere to a portion, considerably below the 
trochanter, and thus the limb will be shortened. 

In a case of fracture of the head of the os femoris 
which occurred in a gentleman of Philadelphia, perma- 
nent lameness ensued, and no union of the fragments 
took place, he died some years after, and upon examin- 
ing the hip joint, a singular instance of the resources of 
nature was presented to view. ^A. ledge of bone was ob- 
served projecting from the trochanter, and upon this the 
acetabulum rested, and thus some weight was sustained 
by the os femoris — it was in fact, an attempt to regenerate 
a neck and head for the bone in a situation where it 
would have been useful, and have enabled the patient to 
walk, had he lived until it was completed. He never 
was able after the accident to bear much weight on the 
affected side. The bone is now in Dr. Physick's pos- 
session. 

Fractures of the lower extremity of the os femoris un- 
less they are situated within the joint, call for no pecu- 
liarity of treatment, but are to be managed just as when 
they occur higher up in the bone. 

Sometimes, however, the fracture detaches a portion of 
one condyle from the rest of the bone (Fig. 5.) Some- 
times a fracture separates the condyles from each other, 
and both from the rest of the bone by a double fracture, 
analo2;ous to that which occurs in the lower end of the 
humerus, as in Fig. 4. 

VOL. I. 25 



iSQ ELEMENTS OF SURGEKY. 

The fracture in which the condyles are thus separated 
from the os femoris may be known, by a perceptible se- 
paration, increasing the width of the knee. The patella 
sinking into the chasm between the condyles, renders the 
part flatter than natural : if the patella be pressed back- 
wards the condyles are still further separated : if on the 
contrary, pressure be made on the sides of the knee, the 
knee resumes its usual breadth and appearance : by mov- 
ing the fragments, crepitation may be heard. Where only 
one condyle is detached, it can be felt moving under the 
fingers, and producing crepitus when rubbed against its 
fellow. 

Sometimes this accident is complicated with a lace- 
rated wound, from the bone being forced through the 
skin, or from the cause of the accident penetrating to the 
cavity of the fracture, and of the joint, thus producing a 
compound fracture, with an exposure of the joint : a ter- 
rible accident, attended with all the dangers resulting 
from lacerated wounds of the larger joints, and demand- 
ing the same mode of treatment, with the additional mea- 
sures necessary for maintaining in contact the fragments 
of the bone. 

The treatment necessary in these cases, varies accord- 
ing to their circumstances. If a fracture exist an inch 
above the knee joint, and this fracture be attended with 
a shortening of the limb, (which will be the case if it be 
an oblique fracture,) and if in addition to this, a second 
fracture separates the condyles extending to the first, as 
in Fig. 4. In this case the permanent extension is to be 
applied, as in fractures of the body of the thigh bone with 
the omission of the pasteboard splints, this will prevent 
the upper fracture from displacement, and in order to 
keep the condyles in contact at their fractured surfaces a 
roller or bandage of strips must be applied, reaching from 



ELEMENTS OF SURGERY. ^gy 

the ankle to the middle or upper part of the thigh, and 
applied pretty tight at the knee. 

If the upper fracture be transverse, no necessity exists 
for permanent extension, and therefore simple pasteboard 
splints may be applied, or the long splints as in the pre- 
ceding case, omitting to apply the extending force. The 
lateral pressure is in these cases the chief indication, and 
to prevent the foot and leg from swelling, a roller should 
be applietl from the foot to the knee. The usual anti- 
phlogistic remedies are to be employed if inflammation 
run high, and the apparatus must be kept on eight weeks 
before any motion is attempted ; as soon as the parts 
have united firmly, tlie limb must be gently and repeat- 
edly moved, to prevent false anchylosis, or stiffness of the 
joint. The patella should be moved frequently, and the 
posture of the leg whilst at rest, often varied. 



188 ELEMENTS OF SURGERY. 



EXPLANATION OF THE PLATE. 

Fig. 1. Represents a fracture of the head of the os fe- 
inoris. 

Fig. 3. A fracture of its neck. 

Fig. 3. A common oblique fracture near the middle of 
the bone. 

Fig. 4. A fracture at the lower extremity of the bone, in 
which the condyles are detached from the body 
of the OS femoris and from each other. 

Fig. 5. Shews several directions a, b, c, d, in which the 
different condyles are occasionally fractured. 

Fig. 6. Represents the relative situation of the fractured 
ends of the hone in the cases mentioned in page 
128, in which the seton was unsuccessfully tried 
for the cure of an artificial joint. The dotted 
line shews the course of the seton, which passed 
through an indurated mass of flesh, and did not 
come in contact with the bone. From this view 
it is evident, that in such cases, the seton cannot 
be successfully used. 



/v. 






fh^'i'-'^- 




■.S.f>»>v^f ,M. 



..A 



E 



PhA tj: . vji. 




ELEMENTS OF SURGERY. 



EXPLANATION OF THE PLATE. 



183 



The opposite engraving represents the apparatus for per- 
manent extension, employed by Desault in oblique 
fractures of the os femoris. 

AA. The external splint, with a notch and a mortise at 

the lower end to fix the inferior extending roller. 
BB. A bandage passing round the body, intended to se- 
cure this splint against the pelvis. 
CC. The anterior splint, reaching only to the knee. 
i. d. d. d. The anterior bolster, extending along the 

whole limb, and secured by pieces of strong tape. 
EE. A portion of the bandage of strips, seen between the 

anterior and the external lateral bolsters. 
FF. The junk-cloth intended to be folded round the two 

lateral splints. 
g. g. The superior extending roller, passing round the 

end of the external splint, and fixed underneath on the 

tuberosity of the ischium. 
H. The sub-femoral roller or strap, intended to prevent 

the bandage BB, which passes round the body, from 

slipping upwards. 
Kk, A roller usually passed round the foot, to prevent it 

from turning. 
L. The inferior extending roller, fixed in the mortise and 

the notch of the external splint. 



190 ilLEMENTS OF SURGERY. 



EXPLANATION OF THE PLATE 

Kepvesenting Dr. Physick's modification of Desault's 
apparatus. 

AA. Dr. Pliysick's long splint. 

B. A block fastened near its lower end, projecting at 
right angles from the splint, over which the extending 
band passes and is tied at the mortise C. 

D. The crutch-like extremity fitted to the axilla. 

E. The edge of the inner splint which extends from the 
perineum below the foot. 

F. The splint cloth wrapped round the external and in- 
ternal splints. 

G. The counter-extending band passing under the tube- 
rosity of the ischium, and secured at the mortise, at the 
upper end of the splint. 

H. The anterior splint of pasteboard (a similar one is 
placed on the back part of the thigh.) 

The bandage round the pelvis is omitted to prevent con- 
fusion. 



ELEMENTS OF SURGERY. ^Q^ 

CHAPTER XXX. 

Fractures of the Patella. 

These may be longitudinal^ transverse, or oblique; 
but in general they are transverse. They are occasioned 
by falls, blows, and accidental violence, and also in some 
cases by the exclusive action of the extensor muscles of 
the leg: of this many instances are recorded. I have 
myself met with two, one of which occurred in a rider at 
the circus, who in vaulting into his saddle from the ground 
whilst his horse was in full speed, suddenly fell, without 
knowing the cause ; a sharp pain at the knee informed 
him of the seat of the injury. Upon examination, I 
found the patella fractured transversely, and tlie upper 
half, draAvn to a considerable distance from the lower. 

It sometimes, though very rarely happens, that the 
tendon above or below the patella is fractured, and not 
the bone. The mode of treatment are in both cases pre- 
cisely similar. 

A fracture of the patella is readily distinguished. If 
it be transverse the patient cannot extend the leg, he 
generally falls and is unable-to rise; though sometimes 
he gets up, and by dragging the limb sideways, is even 
able to walk, taking great care not to bend the knee. A 
depression at the place of fracture is perceived, and com- 
monly, the superior fragment is found at a considerable 
distance from the inferior, which being tied firmly to the 
tibia, cannot move upwards. The longitudinal and ob- 
lique fractures can be known by examination with the 
fingers, as the bone is very thinly covered. 

It has been a matter of doubt among surgeons whether 
bony reunion ever takes place between the fragments of 



193 ELEMENTS OF SURGERY. 

a broken patella. When the distance between them is 
considerable, a firm ligamentous or tendinous matter con- 
nects them, and the motion of the joint after a time is re- 
gained. When, on the contrary, they are kept in close 
contact, the uni(m is hard, firm, and unyielding; whether 
it is bone, tendon, cartilage or ligament, is an object of 
more curiosity than utility. 

The great object to be attended to in the treatment of 
fractures of the patella, is to preserve the fragments as 
nearly as possible, in apposition, so that the substance 
connecting them may be rendered as short as possible, 
and the motions of the joint be perfectly preserved. 

Whenever the fracture is occasioned by a violent blow, 
and great contusion is produced by it, there is reason to 
apprehend inflammation and swelling of the knee, in 
which case bleeding and the usual remedies for inflam- 
mation are to be employed. The local treatment consists 
in keeping the limb at rest in an extended posture, and 
by a splint and bandages preserving the contact of the 
fragments. The chief obstacle to be encountered, is the 
action of the extensor muscles ; and this is easily over- 
come, by the application of a stiff splint behind the limb 
secured by a roller. 

A variety of machines have been constructed for the 
purpose of preserving the permanent extension of the leg, 
and most of them answer very well. I have always em- 
ployed a very simple one. It consists of a piece of wood 
half an inch thick, two or three inches wide, and long 
enough to extend from the buttock to the heel ; near the 
middle of this splint, two bands of strong doubled muslin 
a yard long, are nailed, at a distance of six inches from 
each other. Upon this splint, covered with compresses of 
soft flannel or linen, so as to fill up the inequalities of the 
limb, the patient's leg and thigh are placed. An assistant 
now raises the heel, and the surgeon applies a bandage 



ELEAfENTS OF SUTIGERY. |Q3 

(a common muslin roller, two inches wide, and eight or 
ten yards long,) commencing at the ankle, and proceed- 
ing to the knee ; he carefully draws down the upper frag- 
ment of the bone as nearly as possible to the lower one, 
and places a compress of folded linen above it; several 
turns of the bandage are now made over this compress 
and obliquely under the knee, in such a manner as to 
cross below the lower and above the upper fragment al- 
ternately, in the form of the figure 8 ; the bandage is then 
carried on to the top of the thigh and brought down over 
the splint, leaving the band attached to it, free. Care 
must be taken to cover every part of the skin with the 
roller, because any part which is not thus supported will 
swell and inflame. After the dressing has proceeded 
thus far, the bands of muslin are to be used for the pur- 
pose of more completely fixing the fragments ; the lower 
one is to be passed round the thigh above the upper frag- 
ment, and vice versa, the upper strap passed below the 
lower and secured by a pin or knot. These bands will 
thus enable the surgeon to exert any requisite compres- 
sion upon the fragments without the inconvenience of 
moving the bandage or splint. 

It is evident that this apparatus is in principle the 
same as Boyer's. I claim no merit for its construction, 
but one advantage it certainly possesses ; it may always 
be procured in a few minutes, as a shingle or strip of 
wood and a couple of nails are the only materials neces- 
sary for its formation ; and this in country practice is an 
object of no small importance. I have never employed 
any other mode of treatment, in the cases of this accident 
which have fallen under my care, and in all these, it has 
completely answered my expectations ; the union of the 
fragments has taken place very quickly and in two cases 
without any perceptible interval or motion between them. 
The patient must be kept lying on his back on a mattress 

VOL. I. S6 



IQ^ ELEMENTS OF SURGERY. 

and from day to day the bands are to be examined, and 
tightened if necessary. Beyer directs the joint to be 
moved after the twenty-fifth day, to prevent stiffness. 
These motions, if commenced so early, should be very 
gentle, but they may safely be delayed until the fourth 
or fifth week. In six or seven \^eeks the union is gene^ 
rally completed. 



ELEMENTS OF SURGERY. igg 

CHAPTER XXXI. 

Fractures of the Leg. 

The tibia and fibula are sometimes broken singly and 
sometimes both are fractured. The fracture may happen 
at any part between the knee and ankle. The fracture of 
both bones is most frequent; it may be transverse or ob- 
lique, simple or compound, comminuted or single. The 
fragments are occasionally displaced in every direction. 
In transverse fractures, there is generally no shortening 
of the limb, but in those which are oblique, the leg is 
generally shortened : patients have been known to walk 
many steps without great inconvenience, after having 
fractured the tibia transversely, in consequence of the 
want of derangement. 

Fractures of the leg are characterized by the general 
symptoms of fracture. Deformity of tlie member; loss of 
power to move the limb ; great pain at the time of frac- 
ture, and on every motion of the part, crepitation, &c. 

The higher up the fracture is situated, in general, the 
more favourably does it terminate : very little danger of 
derangement exists when the upper extremity of the bones 
are broken, as the bulk of the tibia at this part, affords 
large opposing surfaces, which support each other, and 
prevent displacement. Oblique fractures of both bones 
of the leg it is sometimes very difficult to manage ; they 
are attended with great inflammation from the irritation 
of the sharp fragments. 

The treatment varies according as the fracture is 
transverse or oblique. A transverse fracture, is very 
easily reduced and maintained in its proper situation. 
One assistant grasps the knee, and another the foot, ex- 



196 ELEMENTS OF SUHGEIIY. 

tension and counter-extension being made, the surgeon 
replaces the fragments, and judges of this by the de- 
formity ceasing, and by the regularity of the anterior 
edge of the tibia, which is so thinly covered as to be 
easily felt. 

A roller is now to be applied, (or a bandage of strips,) 
very neatly from the ankle to the knee : two pasteboard 
splints soaked in water, are placed one on each side of 
the leg, they should extend from the knee to the sole of 
the foot, in order to confine and prevent the lateral mo- 
tions of the foot at the ankle joint. Over these splints a 
second roller or bandage of strips is to be applied ; the 
splints soon become dry and form a solid case for the 
limb which supports suflRciently the fractured bones. It 
is necessary to avoid bandaging too tight, and to loosen 
the dressings if inflammation render them so, by augment- 
ing the volume of the limb : an observation which is ap- 
plicable to most fractures and should never be neglected. 
The limb is now laid on a pillow, the patient being plac- 
ed on a mattress on his back, two strips of wood as long 
as the pillow, and three or four inches wide, may be tied 
with tapes on the outside of the pillow and answer the 
purpose of a fracture box ; the weight of the foot should 
be supported by a bandage passed round the toes, and 
fastened to the boards on the outside of the pillow. The 
weight of the bed clothes should be sustained by some 
simple contrivance, as the segments of two hoops tied 
together. At the end of six or seven weeks the fracture 
generally unites. 

When instead of a transverse direction, thfr fracture 
has taken a very oblique one, the mode of treatment is 
very different, and permanent extension becomes neces- 
sary: a very convenient mode of applying this was con- 
trived by the late Dr. James Hutchinson. Two splints 
of wood are made, long enough to extend from the knee 



ri^ TE. IX. 




ELEMENTS OF SURGERY. |g^ 

six or eight inches below the sole of the foot ; a mortise 
hole is cut near the lower end of both these splints, and 
the upper extremity of each is perforated with four small 
holes. A piece of wood fitted to the mortise holes of the 
splints, eight inches long, is to be provided. 

In applying this simple apparatus, the patient is to be 
laid on his back, and extension and counter-extensioa 
made as usual ; a pillow is placed under the leg upon 
which is arranged a bandage of strips ; two pieces of tape 
are next to be secured by numerous turns of a roller, on 
each side of the leg below the knee : these tapes are to 
be passed through the four holes in the upper end of the 
splint, and tied, a silk handkerchief is next to be passed 
round the ankle, crossed on top of the foot, and tied 
under the sole. The fracture being reduced, the bandage 
of strips is applied neatly to the leg, and the silk hand- 
kerchief next tied over the cross piece connecting the two 
splints ; by which any necessary degree of extension may 
be permanently applied. 

The annexed plate represents the apparatus and its 
mode of application, very intelligibly. It is particularly 
convenient in compound fractures, because the external 
wound can be dressed daily, without disturbing in the 
slightest degree, the fragments of the bone ; but it cannot 
be used in fractures near the knee or ankle joints, be- 
cause the bands for extension and counter-extension 
would irritate the inflamed parts and could not be borne. 
Excoriation must be guarded against by applying soft 
compresses wherever the skin is irritated by the extend- 
ing forces ; it is convenient to interpose a small compress 
of folded linen with this view, between the tapes and skin, 
or what is equally effectual, to pass the roller once or 
twice round the limb before they are applied. 

In some cases the irritation at the knee is very great, 
and the leg swells from the pressure of the circular band- 



198 ELEMENTS OF SURGERY. 

age below it : when this happens in oblique fractures of 
the leg, the long splint of Desault must be substituted, 
and the counter-extension made against the pelvis. It is 
to be applied in the same manner as to a fractured thigh, 
excepting that the leg must be dressed with the bandage 
of strips ; the two long splints are all that will be found 
necessary. 

It is of great consequence in all oblique fractures of the 
leg to attend particularly from day to day, to the form of 
the limb, and the position of the foot, which should be 
supported by a bandage, as before directed, or by a prop 
of wood attached to the splints or bedstead. If the heel 
sinks too low, so as to cause the lower fragment to fall 
downwards, a piece of folded linen or flannel must be 
placed under it. 

The general treatment of the patient is of great import- 
ance in these cases, and blood-letting is to be performed 
as often as the degree of fever and inflammation may in- 
dicate. It is by far the most convenient mode of deple- 
tion, and the most efficacious. 

Compound fractures of the leg, are from the thin 
covering of the tibia, and its exposure to accidents, more 
frequent than any other compound fracture. The general 
directions for their treatment have already been detailed. 
But it may not be improper to remark in tliis place, that 
the permanent extension kept up, either by Desault's or 
Hutchinson's splints, enable the practitioner to dress the 
fracture, as often as necessary, without any pain, or in- 
convenience to the patient, and without retarding the pro-i 
gress of the cure by moving the fragments of bone — circum- 
stances of great importance at all times, but particularly 
in warm weather when the dressings must be very fre- 
quently changed. Should the discharge be very copious 
from a compound fracture of the leg, the pillow upon 
which it rests should be covered with thin oiled silk, to 



ELEMENTS OF SURGERY. igg 

prevent its imbibing the offensive matter, and great clean- 
liness sliould be observed. 

Fractures of the tibia alone, sometimes happen : 
the fracture is generally transverse and attended with but 
little derangement of the fragments. Tlio fibula being 
uninjured, prevents the shortening of the limb, and as no 
great pain or inconvenience is experienced, the case is 
sometimes not discovered until a considerable time has 
elapsed. A careful examination with the fingers will in 
general, from the thinness of the covering over the tibia, 
enable the surgeon to detect an inequality at the place of 
fracture. Crepitation may also in general, be occasion- 
ed, by forcibly pressing the fragments in opposite di- 
rections. 

The treatment of the case is extremely simple; rest on 
a pillow, is all that is essential, but it is most prudent to 
apply the dressings recommended for transverse fractures 
of both bones of the leg, and to keep the patient in bed 
until the cure is effected, viz. forty or forty-five days. 

Fractures of the fibula are less frequent than 
those of the tibia, notwithstanding its slender size, owing 
in great measure to the circumstance that it is not con- 
cerned in supporting the weight of the body. 

The chief causes of fractures of the fibula, are a violent 
blow on the outside of the leg, or a forcible abduction of 
the foot. There is reason to believe that in many cases 
of sprained ankle this fracture exists without being 
known. No shortening of the limb takes place, and the 
only displacement observed, is the fragments being push- 
ed inwards towards the tibia. 

To ascertain the existence of the accident, the bone 
should be pressed inwards, and crepitation will generally 
be perceived, or at least a motion of the bone at the place 
of fracture. 

The mode of treatment^ consists, in an attempt to force 



goo ELEMENTS OF SURGERY. 

the fragmente outward by abduction of the foot, and by 
pressure upon the interosseous muscles after which two 
pasteboard splints are to be applied, as in transverse 
fractures of both bones of the leg, and the patient must be 
kept at rest thirty or forty days. The splints are chiefly 
useful by keeping the ankle joint at rest. 

The approximation of the fibula to the tibia, is not so 
important as that of the radius and ulna, because no rota- 
tory motion exists between the bones of the leg. A 
slight stiffness of the ankle joint is commonly a conse- 
quence of fractures of the fibula, but it soon subsides with- 
out any remedy but exercise. 



ELEMENTS OF SURGERY. gOl 

CHAPTER XXXII. 

Fractures of the bones of the Foot. 

Fractures of the os calcis are very rare, but occa- 
sionally happen. The accident may be detected by a 
crack at the moment attended with severe pain at the 
part, and great difficulty in standing upright, a swelling 
of the heel and mobility of the fragments attended with 
crepitation. 

To reduce the fracture, the leg must be flexed upon the 
thigh, and the foot extended on the leg. In which situa- 
tion the fragments can readily be reduced. Boyer di- 
rects in order to retain the fragments, the slipper in- 
vented by Petit, for a rupture of the tendo achillis, or if 
that cannot be procured, the uniting bandage used for 
transverse wounds, modified as follows. The end of a 
bandage is placed on the superior surface of the foot, 
whence the bandage is reverted on the sole, and the end 
is made fast by circular casts around the foot ; this band- 
age is then drawn along the posterior side of the leg to 
the ham, the foot being previously extended, on which 
part it is fixed by other circular casts, it is thence brought 
downward forcibly, and the application terminated by 
rolling along the leg what remains. To this bandage 
may be added a long compress, the middle part of which 
should be applied above the posterior portion of the os 
calcis, and the extremities crossed on the superior sur- 
face of the foot, and turned under the sole ; this compress 
may be fixed by a bandage rolled on the foot in the shape 
of the figure 8. The union of the fracture is eifected in 
thirty or forty days, at the end of which time the patient 
may be allowed to bend his foot. He must, however, for 

VOL. I. 37 



%02 ELEMENTS OF SURGERY. 

some days, avoid any forced flexion of the foot, as also 
any excessive extension by rising on his toes." 

" The other bones of the tarsus, as the astragahis, cu- 
boides, scaphoides, and three ossa cuneiformia, are sus- 
ceptible only of comminutive fracture. The same may be 
said of the bones of the metatarsus and phalanges of the 
toes.'' The treatment of these fractures can be very suf- 
ficiently understood from what has been said of fractures 
of the bones of the hand, to which they are analogous. 



ELEME>rTS OF SURGERY. gQg 

CHAPTER XXXIII. 

Of Wounds of Bones. 

In the following observations on the denudation and 
wounds of bones, I shall avail myself chiefly of the la- 
bours of Boyer and Hunter. ' 

The bones may be stripped, not only of the integu- 
ments, muscles, &c. by which they are naturally covered, 
but also of the periosteum, which is their intimate and ap- 
propriate covering. 

Cutting or contunding instruments may produce this 
denudation of the bone, without injuring its substance, or 
they may cut or contuse its external fibres. These two 
cases must be carefully distinguished, as the contusion of 
the bone is attended with consequences much more seri- 
ous than those of a simple denudation. 

If the bone has been merely stripped of its perios- 
teum and integuments, and those parts are immediately 
replaced, so as to exclude the contact of the air and band- 
ages, tlie reunion of the periosteum is found to take 
place in a very short time. But if the external lamina of 
the bone has been contused, or if its surface has been 
left a long time exposed to the action of the air, or to the 
friction of bandages, exfoliation becomes a natural conse- 
quence. All the external lamina must separate ; and be- 
fore this separation is effected, the cicatrization of the 
external wound would be rather injurious. Should the 
wound in the integuments be prematurely closed, puru- 
lent matter will continue to form underneath, the con- 
tused lamina will exfoliate, an abscess will point exter- 
nally and burst spontaneously, and the matter that 
escapes from it will contain small splinters of bone. 



g04j ELEMENTS OF SURGERY. 

Old age is unfavourable to the healing of wounds and 
contusion of the bones , because as the cure can be ef- 
fected only by means of the vascular texture of the bone 
and periosteum, the turgescence and expunsion of this 
must be slow and difficult in proportion to the person's 
age. The treatment adapted to the different cases is as 
follows. 

If the bone be simply laid bare, the integuments, if not 
completely separated, should be instantly replaced. This 
precept holds good in all cases, whatever may be the 
patient's age, if the bone has not been already exposed 
to the contact of the air. At the same time it must be 
allowed, that it is very difficult to know by mere inspec- 
tion, whether the bone be contused or not; but should 
that be the case, and even should suppuration and exfo- 
liation be inevitable, no bad consequences can result 
from the attempt to produce an immediate cicatrization; 
whereas, in the contrary event, the duration of the treat- 
ment will be much abridged. If it be possible to unite 
the wound by the first intention, its lips are to be kept 
separate by lint interposed, and the whole is to be lightly 
covered. In a short time granulations appear, and the 
external lamina of the bone exfoliates. Sometimes, how- 
ever, and particularly in young person, the bone becomes 
soft and red, and granulations arise from it, which bleed 
from the slightest cause. It has been said that the bone 
exfoliates insensibly in this case ; but this observation is 
not found to be true : the laminie of the bone are not 
broken down, dissolved, and carried off by suppuration. 
The change consists of a softening of the bone, and con- 
version of it into a fleshy substance, which unites with 
the soft parts. 

In this last mentioned case, the cure is much more 
prompt than when a real exfoliation takes place. The 
process of exfoliation resembles that of the separation of 



ELEMENTS OF SURGERY. gQg 

gangrenous eschars : the mode in which the separation 
is eflPected, is equally unknown in both cases.* In exfo- 
liation, it is merely known that the subjacent vessels 
grow turgid, expand, and pullulate, and that a line of 
separation is observed between the contused lamina? and 
the sound part of the bone. The former are undetermin- 
ed, as it were, and their connexion shaken by the puru- 
lent matter formed under them, and at length are entirely 
detached, and may be easily removed by the fingers or a 
forceps. When the bottom of the wound is entirely freed, 
the granulations that arise from it, 'unite with the soft 
parts, and in a short time the wound is cicatrized. 

Various processes have been employed for expediting 
the exfoliation. Thus the ancients covered the bone with 
pledgits of lint impregnated with spirits, or with a tincture 
of myrrh and aloes; but it is found, that these applications 
retard the exfoliation by opposing the expansion of the 
vessels ; for which reason they have been laid aside, and 
oily relaxing applications liave been substituted for them. 

It has been proposed to perforate in different parts the 
laminae which are to exfoliate, on the supposition that 
this practice facilitates the growth of the granulations. 
The perforations certainly have this efiPect, but the granu- 
lations by shooting up through them, retain the laminae 
rather than aid their exfoliation : each vessel spreading 
as it rises, and assuming in some respect the shape of a 
broad-headed nail. It will then be more prudent to limit 
the treatment to the use of unctuous or emollient applica- 
tions. By means of these remedies, the texture of the 
part will be sufficiently relaxed, and the devclopement of 
the vessels facilitated. But if the portion of the bone to 
be exfoliated be very considerable and deep seated, these 

• Mr. Hunter has fully explained this formerly unintelligible process. See 
pag-e- 307 of tlie present volume. 



306 ELEMENTS OF SURGERY. 

applications are nearly useless, at least their eifect must 
be very trifling ; then we must content ourselves with 
covering the part m ith lint, and trusting to time and na- 
ture for effecting the separation. 

Though the exfoliation be complete, as may be known 
by the motion of the piece, it may still happen that the 
circumference of the detached portion may be encroached 
on by the growth of the soft parts, and thus prevented 
from separating. In this case it will be necessary to dis- 
engage it by making an incision in some point of the cir- 
cumference of the wound, after which it may be drawn 
out by the fingers or a forceps. In general there is but 
very little difficulty in removing it. 

The action of cutting instruments is not always limit- 
ed to the mere denudation of the bone ; they sometimes 
completely divide it : this, however, is but a rare occur 
Fence. It sometimes happens that a part of the bone is 
cut off, of which there are numerous instances in wounds 
of the head, where a part of the parietal bone, with its 
pericranium, a portion of the occipito-frontalis muscle 
and hairy scalp, have been entirely separated by a blow 
of a sword. 

When a wound of the soft parts is accompanied by a 
similar affection of the subjacent bone, an immediate re- 
union of the soft parts must not be attempted. Lint is to 
be gently introduced into the fissure, and the wound heal- 
ed from the bottom ; for a solid cicatrix of the soft parts 
cannot be expected until the wound in the bone is first 
cicatrized. 

If the bone in one of our limbs be cut quite through, 
as in the cases mentioned by La Peyronie, Warner, and 
others ; and if a piece of flesh remain undivided, which 
contains the principal vessels of the limb, it will be pru- 
dent to reunite the parts, and place the limb in the appa- 
ratus used in cases of fracture of the part. 



ELEMENTS OF SURGERY. gQ^ 

The time necessary for the reunion of the parts in cases 
of this nature, is full as long as that in those of fracture, 
and the consolidation is effected in the same manner as 
iu the former case. 

In the preceding remarks, Mr. Boyer has not attempt- 
ed to explain the manner, in which bone that has been 
contused and suffers death, in consequence of a blow, 
separates from the living bone with which it is iu contact. 
I shall therefore state in this place the opinion on the sub- 
ject, taught by Mr. Hunter, and now generally adopted. 

Exfoliation is the separation of dead from living 
bone, as sloughing is the separation of dead from living 
flesh, and the process in both cases, is effected in the 
game manner, by the action of the absorbent vessels. 
There is nothing like a melting down of the bone ; no 
solution takes place ; the bone separated is solid and in 
texture unchanged, and the term exfoliation was derived 
from the scales or leaves of bone thus detached. la 
bones which are most solid, and have fewest cells, the 
separation takes place most rapidly. I have known a 
portion of the radius exfoliate in a few days, and I have 
known the os calcis, several years in casting off a por- 
tion of dead bone. The entire death of a portion of bone, 
is necessary to its exfoliation, and hence, in some cases, 
the hot iron may be used with advantage in expediting 
the process, by destroying the life of diseased bone. 
According to Mr. Hunter, caustics and hot irons may ex- 
pedite exfoliation in two ways, first by killing the bone, 
and secondly by inflaming the adjacent bone, and thus 
increasing its vascularity and its actions. Dead bone 
like all other extraneous matter, stimulates the adja- 
cent parts, in consequence of which they become more 
vascular. The bone is composed of animal gluten, and 
earth ; the earthy portion of the living bone, is removed 
by the action of the absorbents ; just as in health these 



gO§ ELEMENTS OF SURGERY. 

vessels perform the process of interstitial absorption, re- 
moving from time to time the solid parts of the body. The 
consequence of this absorption of the earthy particles from 
the bone, must necessarily be, that the bone is converted 
into a soft matter, which is interposed between the living 
solid bone, and the dead solid bone. The soft substance 
thus interposed, is last of all absorbed, and the dead bone 
left without any connection with the living. We are, 
therefore, to consider the living bone as effecting the 
whole business of exfoliation, through the agency of its 
absorbing vessels, and these vessels act on the living 
matter, and perhaps also, on the dead part immediately 
in contact with it. 

The process of exfoliation begins at the surface of the 
bone, and proceeds irregularly, not progressing uniform- 
ly, in the same direction, or with the same celerity in 
every part ; circumstances not easy of explanation. Dur- 
ing the continuance of this absorption of the bone, granula- 
tions of a fungous nature, shoot out from the surrounding 
parts, and by pressing on the loosened bone, push it out- 
wards towards the surface of the body, in the same man- 
ner as any other loose extraneous matter would be cast 
off, by the ulcerative process. 

The edge of dead bone, presents an unequal ragged 
surface, ^' a groove or worm eaten canal" being inter- 
posed between it and the sound bone. 

The highly interesting physiology of the absorbent 
vessels, aud their agency in this process, have been most 
ably developed by the late John Hunter, the first writer 
who threw any light on the subject. 



ELEMENTS OF SURGERY. ^g 

CHAPTER XXXIV. 

Of Dislocations. 

A Dislocation or Luxation signifies the escape of 
the articulating surface of a bone, from its natural situa- 
tion ; as of the head of the thigh bone from the aceta- 
bulum. 

A knowledge of anatomy is essential to the comprc'- 
hension of all surgical cases^ but the reduction of dislo- 
cated bones in some instances occasions great difBcultj^, 
and calls for a complete and accurate knowledge of the 
parts ccncerned informing the joints, and of the effects of 
the muscles acting upon the displaced bone ; a kind of 
knowledge not to be obtained simply from osteology or 
a study of the skeleton, but demanding a frequent inspee- 
tion of the fresh joints, covered with cartilage and sur- 
rounded with ligaments, &c. 

Some bones in consequence of the structure of their 
joints and their exposure to accidental violence, are very 
fiequently luxated, as the os humeri at the shoulder ; 
otliers from opposite circumstances, arc very rarely dis- 
located, as the vertebrae. In general the liability to luxa- 
tion is proportionate to the degree of motion which the 
joint possesses, and hence the ball and socket joint al- 
lowing motion in all directions, is the seat of dislocation 
most frequently. In the joints possessing a hinge-like, 
or ginglimus motion, the accident is proportionally rare, 
in consequence of the greater extent of the opposing sur- 
faces forming the joint, and of the strength of the liga- 
ments which surround them, added to which, they are 
less frequently exposed to force in a direction proper for 
separating their articulating extremities. 

vf)i . V. 28 



ol(j ELEMENTS OF SURGEIIY. 

Luxations are said to be complete, when the bones of 
the joint are entirely separated ; incomplete, when some 
portion of the articulating bones remain in contact. The 
only instances of incomplete luxation occur in the articu- 
lations by ginglimus ; as the knee, elbow, or foot ; and 
here a complete luxation is very rare, from circumstances 
obvious to every one who is conversant with the struc- 
ture of these joints. 

The longer a bone is suffered to remain in the new 
situation into which it has been forced, the more difficult 
will it be found to reduce it to its natural place. The 
soft parts having accommodated themselves to the new 
position ; the muscles being shortened ; after a longer 
time, adhesions forming ; and lastly, actual concretion of 
the dislocated bones in a situation remote from the joint, 
or the formation of a new moveable joint ; these are cir- 
cumstances which increase the difficulty of replacing the 
luxated bone, in proportion to the length of time which 
has elapsed after the accident. 

Luxations like fractures, have been divided into sim- 
ple and COMPOUND. The simple being accompanied 
with no external wound, the compound having a wound 
communicating with the cavity of the joint, formed either 
by the protrusion of the bone through the integuments, or 
by the cause of the luxation dividing them at the time of 
the accident. Luxations may be complicated with vari- 
ous other mischief, by the injury of blood-vessels, 
nerves, &c. 

The immediate causes of the luxation of a bone are vio- 
lence applied to the joint, and the action of muscles. In 
an enarthrosis joint (ball and socket) if the direction be 
not oblique, it is impossible for the bone to be dislocated. 
Boyer has illustrated this by the example of the os hu- 
meri. If this bone " hang exactly along side of the body, 
or perpendicularly with respect to the glenoid cavity of 



ELEMENTS OF SURGEEY. gi 4 

the scapula, no force is capable of luxating it. If a per- 
son fall on the elbow while the fore-arm is in this posi- 
tion, the head of the humerus will be forced against the 
cavity formed to receive it; but if the arm be removed 
from the body, the axis of the os humeri will fall ob- 
liquely on the surface of the glenoid cavity, which will 
favour its passing out of the socket; and this disposition 
to luxate, will be encreased in proportion as the angle 
formed by the axis of the bone with the surface of the 
cavity deviates from a right angle. 

The action of muscles probably very often assists in 
dislocating bones ; sometimes no other cause exists. I 
have known the patella dislocated laterally, by a lady in 
dancing, and in convulsions different bones are occasion- 
ally luxated. 

Some joints we have already noticed, are more liable 
to dislocations than others. This predisposition may de- 
pend on great latitude of motion ; on the small extent of 
articulating surfaces in contact; the laxity and small 
number of the ligaments uniting them ; paralysis of the 
muscles surrounding a joint ; and whatever has a ten- 
dency to weaken the different connections between the 
bones. 

In some instances the soft parts connecting the bones, 
are so relaxed that a very slight force suffices to dislocate 
them. I have known a woman whose shoulder was liable 
to luxation from exertions of the most trifling force, and 
Boyer relates the case of a patient who could not yawn 
even moderately without dislocating her jaw. These 
luxations are, from the same relaxation which gives rise 
to them, very readily reduced, unless this process be too 
long delayed. 

Boyer declares, that " whatever may be the manner in 
which the causes act, luxations are always accompanied 
with more or less laceration of the ligaments surround- 



2i2 ELEAftNTS OF SUKGERY. 

iiig the joint ; and in the round articulations, as those of 
the shoulder and hip, the fibrous capsules are always 
torn." He ought to have excepted cases similar to those 
noticed in the last paragraph. 

The symptoms which distinguish luxations, are pain 
and inability to move the member, a change in the ap- 
pearance of the joint, an elongation or shortening of the 
limb, an impossibility of performing certain motions. 
By careful examination the displaced bones may often be 
felt in their new situations ; producing eminences where 
there are naturally depressions, and vice versa ; but a 
more explicit account of these symptoms will be deli- 
vered when the different luxations arc particularly de- 
scribed. 

The treatment of dislocations consists in replac- 
iug the bones, and retaining them in their natural situa- 
tion. The reduction is to be effected as in fractures, by 
extension and counter-extension. There is in general no 
difficulty in keeping the bones in their natural position 
when they have once regained it. 

The principal obstacle to the replacement of a bone, 
recently dislocated, is the action of muscles drawing its 
articulating surface into a situation remote from that, 
which it ought to occupy. It frequently happens, that 
after the head of a bone has been forced out of its na<,:ral 
place, it passes over certain bony prominences, and then 
takes a situation in a depression of bone, from which it 
must be forcibly raised before its reduction can be ef- 
fected. Instances of these bony resistances to the reduc- 
tion are found in luxations of the thigh bone ; the head of 
the femur passing over the high mai-gin of the acetabu- 
lum lodges in the foramen thyroideum, or on the dorsum 
ilii, and before it can be replaced in its natural socket, 
it must reascend the prominences over which it has 
passed. 



ELEMENTS OF SURGERY. gj^g 

For the purpose of applying extension and counter- ex- 
tension for the reduction of luxated bones, a variety of 
machines have been contrived, which it is unnecessary 
to detail in this place. The only means at present in 
use, are the hands of assistants, and compound pullies. 
Whenever we can avail ourselves of the aid of a suffi- 
cient number of assistants, this mode of applying force is 
to be preferred, because its direction and degree may be 
altered instantly by a word. 

The parts to which force should be applied in reduc- 
ing luxations, can be better explained by describing the 
different dislocations, than by any general rules. In 
most cases the force should be made to act as directly as 
possible upon the affected joint. Boyer and the gene- 
rality of French surgeons direct, on the contrary, that 
'" the extending force should be applied not on the luxat- 
ed bone, but on that with which it is articulated, and as 
far as possible from it." A rule which can be applied 
with advantage to very few cases.* 

The degree of force to be employed can only be esti- 
mated by the difficulty of the reduction, it should always 
be sufficient to accomplish that end. Althougli it is to be 
constantly recollected, that force alone is never to be re- 
lied on, but skill in the direction of it is ever to be exert- 
ed. A force sufficient to tear oft' a limb has been ap- 
plied without reducing a dislocation. In estimating the 
force to be employed, the obstacles to be encountered 
should be carefully kept in view, and when these are 
clearly understood, the direction of the extending powers 
and the degree of their violence will be the more easily 
judged of. It should in every instance be gradually 
applied : Mr. Pott remarks, that " whatever kiud or de- 
gree of force may be found necessary for the reduction of 
a luxated joint, that such force be employed gradually ; 

• Mr. Pott advocates the piinciplc I have recommended, and most of the 
Bpitish svirg^eons, as uausj, oppose thcFrcjich. 



214? ELEMENTS OF SURGERY. 

that the lessey degree be first tried, and that it be in- 
creased gradatim." This important rule if carefully 
observed will prevent all serious mischief from the use of 
the force necessary even in the most chronic luxations. 

Napkins and strong bands or girths, fastened upon the 
limb by means of cotton rollers, enable the requisite num- 
ber of assistants to act at the same time. To prevent ex- 
coriation of the skin where great force is necessary, Dr. 
Physick has applied a piece of buckskin with advantage, 
between the cuticle and the extending bands. 

Counter- extension applied to the bone with which the 
luxated one was articulated, should always be made at 
least equal to the extension. If for example, three as- 
sistants are employed in extending a luxated arm, a force 
equal to three should be employed in fixing the scapula. 
Counter- extension may often be made by securing a band 
to a staple in a wall, or some secure position. 

In attempting the reduction of difficult luxations the 
position of the patient should be changed. After an erect 
posture has been tried, a recumbent one should be sub- 
stituted ; if this fail, the patient may sometimes with ad- 
vantage be seated in a chair. 

" Great advantage is derived in the reduction of dis- 
locations from attending to the patient's mind; the mus- 
cles opposing the efforts of the surgeon, by acting in 
obedience to the will, may have that action suspended by 
directing the mind to other muscles. Several years ago, 
a surgeon in Blackfriar's Road asked me to see a patient 
of his with a dislocated shoulder, which had resisted the 
various attempts he had made at reduction. I found the 
patient in bed with his right arm dislocated ; I sat down 
on the bed by his side, placed my heel in the axilla, and 
drew his arm at the wrist ; the dislocated bone remained 
unmoved. I said, " Rise from your bed sir;" he made 
an effort to do so, whilst I continued my extension, and 
the bone snapped into its socket; for the same reason, a 



ELEMENTS OF SURGERY. g^g 

slight effort, when the muscles are unprepared, will suc- 
ceed in reduction of dislocation after violent measures 
have failed.'^* (Astley Cooper.) 

In recent luxations it has been already noticed that the 
principal difficulty experienced, is in overcoming the con- 
traction of the muscles. The fatigue of the muscles occa- 
sioned by long continued efforts at reduction, often pro- 
duces a relaxation which permits the bone to return to its 
natural place. Dr. Physick many years ago employed 
copious blood-letting with this Wew. He bled the patient 
until fainting was produced, and during his continuance 
in a state of syncope all muscular action being suspend- 
ed, the reduction was readily accomplished. In a great 
number of instances which have since occurred, the prac- 
tice has been found completely successful. There are 
several writers who recommend bleeding to diminish the 
action of the muscles in obstinate luxations, but none 
(so far as I know) who propose bleeding ad deliquium 
animi, except Dr. A. Monro, sen. who suggested in his 
lectures on surgery copious blood-letting from one or both 
arms in an erect posture, as a probable means of facilitat- 
ing the reduction of dislocations ; but Dr. Physick I be- 
lieve was the first who had the boldness to cany the 
practice to the extent necessary for complete success. 
The first case in which it succeeded, was a luxated hu- 
merus, which had baffled every mode of applying force, 
and a very great degree of force had been used. During 
the fainty state, the hands of the operator were the only 
6ieans employed, and in a single moment, without the^ 
slightest difficulty he replaced the head of the bone in its 
socket. 

In cases where blood-letting to the necessary extent is 
inadmissible, other means of suspending the action of the 

" This fl\ct, and the practice detluced from it, have been long since pointed 
out by Dr. Physick, in Iiis Surgical Lectures, and exemplified at the Pennsyl- 
'"ania hospital 



^1(5 ELEMENTS OF SURGERY. 

muscles are to be used. Perhaps nauseating doses of 
emetics, or the tobacco glyster, might be employed with 
advantage.* Intoxication has been recommended. I once 
saw it succeed completely in a case of dislocated jaw, 
which no previous efforts were effectual in reducing. It 
was resorted to by Dr. Physick, on account of the ex- 
treme debility of his patient who was dropsical, and 
whom blood-letting would probably have destroyed. 

The effects of blood-letting ad deliquium animi in faci- 
litating the reduction of dislocated bones, has been very 
strikingly exemplified in several chronic luxations, which 
have occurred in different parts of the United States. 
Dr. Physick reduced a luxated humerus which had been 
out of place forty-five days, with very great facility; 
and in a case tvhich occurred at Baltimore, the arm had 
been dislocated five or six months and was replaced by 
Dr. M'^Kenzie by the aid of the same remedy. f 

* From the surgical essays of Mr. Astley Cooper and Mr. Travers, published 
in this present year, 1818, it appears that blood-letting, the warm bath, and 
nauseating doses of emetics, have been freely employed to diminish muscular 
action, by various British surgeons, and with great success. 

f The following extract of a letter to Dr. Physick, contains the history of this 
truly remarkable case, of the success of which I believe no parallel is to be 
found in the records of surgery. 

" B. J. a seaman aged about thirty -five years, was admitted into the Baltimore 
hospital in the month of September 1805, with a luxation of the os humeri. Tl)e 
account he gave of his case was, that while on a voyage to Liverpool, and t\ro 
weeks after leaving this port, he fell from a considerable height and dislocated 
his shoulder, and that an attempt was made by the captain of the ship to re- 
duce it, but without success ; that upon his arrival at Liverpool repeated trials 
were made to effect reduction of the bone, but to no purpose, and he had now 
remained in this situation hetiueenfive and six months. 

" Upon examining the shoulder, 1 found the head of the humerus under the 
pectoral muscles, where it had imbedded itself, and appeared to Ivave fonned 
considerable connexions with the surrounding parts. 

« In tins state of things 1 deferred any attempt to reduce the bone till the fol- 
lowing day. when in consultation with my friend Dr Smjlh, it was deteimined 
at once, to have recourse to bleeding ad deliquium, as the only plan in our N-iew 
likely to succeed; and having secured our patient iji the usual manner, a vein 
was opened, andncAr\yfvepound»ofl>lood were drawn before fainting could be 



ELEMENTS OF SURGERY. g^y 

An erect posture, as being most favourable to the pro- 
duction of syncope, should be preferred. 

It is proper to remark, however, that after a bone has 
continued several months dislocated, it forms adhesions 
in its new situation ; probably the rent in the capsular 
ligament contracts, or even heals up. Inflammation pro- 
duces great changes in the structure of the parts and in- 
creases greatly the difficulty of reduction. Rotating the 
bone and moving the joint in all possible directions, are 
necessary to destroy these adhesions, and long continued 
efforts sometimes succeed when the surgeon had nearly 
despaired of accomplishing his object. Perseverance, 
therefore, is to be strongly recommended in all recent 
luxations, and even ia those which have existed several 
months. 

To preserve the bone in its proper place nothing but 
rest is necessary. Very little bandaging is required for 
this purpose, but it should be remembered that a joint 
which has been dislocated has suffered necessarily a great 
deal of contusion and that it will probably inflame very 
considerably. The usual means of combatting this in- 
flammation when it occurs, among which rest is indis- 
pensable, are to be employed. It is proper in most cases, 
to bathe a joint which has been dislocated with a solu- 
tion of sugar of lead or with some cooling lotion. 

Luxated bones which are not reduced, sometimes re- 

• 

produced ; this, however, was at length completely efTectedj and with (compa- 
ratively speaking) very little effort the bone was reduced. 

"It is worthy of remark in this case, that neitlicr swelling nor Inflammation 
siKceeded the reduction of the bone, and the poor man was dismissed well in 
the course of two weeks. 

" I am, &c, 

"COLIN M'KENZIE." 

DesauK's most chronic case was of three months duration, and I believe Dr. 
M'Kenzie has accomplished what no othej- surgeon of tiiis or former ages can 
boast of having performed. 

VOL. I. S9 



218 ELEMENTS OF SUUGKRV. 

main in the situation into which they had been at first 
forced; more commonly, however, they change their si- 
tuation, being drawn by the action of muscles further and 
further from the cavity of the joint. In its new situation 
it excites inflammation and a thickening of the surround- 
ing soft parts ; if in contact with bone, this bone becomes 
inflamed, and after a time a depression is formed in 
it which receives the head of the dislocated bone, and 
a kind of imperfect joint is formed ; the muscular flesh 
and cellular texture are changed into a ligamentous mat- 
ter which assist in supporting and strengthening the new 
articulation. In various anatomical collections are pre- 
served curious specimens of tliese newly formed joints, 
affording wonderful proofs of the resources of the animal 
ceconomy. The socket of the joint from whicl) the bone 
had been displaced, sometimes fills up with a thickening 
of the ligaments, and the usual matter of adhesions, 
though in other cases it remains very little changed in 
structure. 

The muscles of a limb permanently dislocated shrink 
and lose their strengtli, and although in some cases a 
power of motion is regained after a time, yet it is always 
very limited and imperfect. 

Of COMPOUND DISLOCATIONS. These are among the 
most dangerous accidents to which the bones are liable; 
all the dangers of wounded joints, and of compound frac- 
tures, are to be dreaded from tliem. The question of 
amputating a limb in which a compound dislocation has 
happened, is attended with all the difficulties, already 
noticed when speaking of wounded joints. The various 
circumstances of the patient in each particular case must 
be taken into view, and no general rules for deciding it, 
can be laid down. 

The principal object in the treatment of compound dis- 
locations is, after reducing the bone, to procure as speedi- 



ELEMENTS OF SURGERY. g j^ g 

ly as possible the union of the external wound, thereby 
piecludin;^; the dangers of an exposed joint. For this 
purpose its edges should be brought as nearly as possible 
into contact, and retained so by adhesive plaister, and 
the joint kept perfectly at rest by bandages, splints, and 
a proper posture. 



ggO Elements of surgery. 

CHAPTER XXXVI. 

Of Particular Dislocations. 

DISLOCATION OF THE LOWER JAW. 

This accident happens generally in adults and never 
in young infants, because in the latter the angle of the 
jaw is obtuse, in consequence of which the condyles by 
which it is articulated with the temporal bones have the 
same direction as tlie basis of the jaw, and from this 
structure the mouth cannot be opened wide enough in in- 
fancy to separate the articulating surfaces. 

Sometimes one and sometimes both condyles are dis- 
located. The only direction in which the displacement 
can happen is forwards. In most cases the accident is 
produced by yawning, or opening the mouth excessively 
wide. A woman in scolding her husband, in a very vo- 
ciferous tone, found herself unable to close her mouth, 
and applied to Dr. Physick who found both condyles 
of the lower jaw dislocated. A blow upon the chin 
whilst the mouth is opened may also occasion the same 
effect. 

The symptoms which denote this luxation, are an in- 
ability to close the mouth, which is kept considerably 
open ; immediately before the ears where the condyles 
naturally occasion a fulness, an empty hollow space is 
perceived ; the coronoid process is felt projecting more 
anteriorly than natural ; the cheeks and temples are flat- 
tened; the saliva flows from the mouth; the patient 
speaks and swallows with great difficulty ; the chin pro- 
jects forward. When the jaw continues dislocated se- 



ELEMENTS OF SURGERY. gQI 

veral days these symptoms are not so strongly marked, 
but they still exist, to a greater or lesser degree. 

To effect the reduction the patient is to be seated on a 
low chair, his head supported against the breast of an as- 
sistant ; the surgeon defending his thumbs with a piece 
of leather, or linen, places them as far back upon the 
molar teeth of the lower jaw as possible, the fingers are 
then placed under the chin, and whilst he presses down 
the back teeth with his thumbs, he at the same time ele- 
vates the chin ; by this manoeuvre he uses the base of the 
jaw as a lever of which his thumbs represent the fulcrum, 
and disengages the condyles from the zygomatic fossje in 
which they had been lodged ; when the condyles are 
found moving, the chin is to be pushed backwards, and 
the reduction is effected. At this mom.ent it behoves the 
operator to be careful in removing his thumbs from be- 
tween the teeth, for the condyles regain their situation 
very suddenly, and the jaws are spasmodically closed, 
with great force. To prevent their being bruised he slips 
them very quickly outwards between the cheeks and 
teetli, where they are safe. 

After the reduction the jaws should be kept at rest a 
few days by a bandage passed round the head and chin, 
the patient being nourished with spoon victuals. 

It has been proposed to reduce this luxation by a sud- 
den I)low on the chin, knocking it upwards and back- 
wards. Tliis plan has sometimes succeeded but it is al- 
ways attended with great danger of breaking off the con- 
dyles of the jaw. 

When only one condyle is dislocated the reduction is 
effected in the same manner as when both are displaced, 
except that only one hand is necessary. 

Le Cat succeeded in reducing an obstinate dislocation 
of the jaw by introducing a stick between the back teeth 
and usin"- it as a lever continually prizing the teeth of the 



gg2 ELEMENTS OF SURGERY. 

upper and lower jaw apart, uutil the muscles which were 
spasmodicallj/- conti'acte<l, became fatigued and then the 
reduction was easily effected. 

Dr. Ph jsick was consulted a short time ago by a young 
woman who had been salivated for the cure of a dropsy, 
the inflammation and swelling of the jaws in consequence 
of the use of mercury were very great, and during the 
continuance of these symptoms she dislocated (without 
knowing how or when) both condyles of the lower jaw. 
When the effects of the mercury had somewhat subsided, 
she perceived her inability to close her mouth, and her 
physician soon discovered that the jaw was luxated. She 
came to Philadelphia, and Dr. Physick attempted its re- 
duction in the usual manner, but not succeeding, the plan 
proposed by Le Cat was tried without effect, her molar 
teeth being almost all carious prevented any violent efforts 
upon them, with the wooden lever. Her extreme debility 
and dropsical habit, precluded blood-letting and I sug- 
gested to Dr. Physick the propriety of trying the nau- 
seating effects of tobacco. She refused this however, and 
the Dr. next proposed to give her as much ardent spirit, 
as should occasion intoxication. She consented and be- 
came perfectly ifiebriated, and whilst inebriated was pre- 
vailed on to smoke a segar, great nausea ensued, duiing 
which time the measures which had been before unavail- 
ing, very promptly succeeded in effecting the reduction'. 



ELEMENTS OF SURGERY. ggg 

CHAPTER XXXVII. 

Dislocations of the Vertebrce. 

The excellent work of Boyer will furnish the follow- 
ing Chapter. 

" The large surfaces hy which these bones correspontl, 
the number and thickness of their ligaments, the strength 
of the muscles lying on the column formed by them, the 
small motion of wliich each verte!)ra is capable, and 
lastly, the vertical direction of their articulating apophy- 
ses, render a luxation of them in the dorsal and lumbar 
part of the column, entirely impossible. A violence, 
tliough ever so considerable, cannot displace them with- 
out first fracturing them. The same is not the case with 
the ctrvical vertebrae ; the extent of their articulating 
surfaces is less, the ligameuto-cartilaginous substance 
which unites their bodies has more pliability, the motion 
of their articulations is greater, and their articulating 
surfaces have an oblique direction, which allows theni 
to have an obscure rotatory motion ; consequently luxa- 
tions of them are sometimes met with. I have seen a 
case in which the neck was luxated by a violent rota- 
tory motion of the cervical vertebrae, and the luxation re- 
sisted all means that were employed to reduce it. The 
cause of impediment was felt towards the middle of the 
column formed by the cervical vertebrae ; from which 
circumstance we may conclude that the dislocation did 
not consist of a separation of the first vertebra from the 
second, which is admitted to be possible by all authors, 
but that it took place lower down in the cervical part of 
the column. 
It appears from well attested fiicts, that luxations may 



234, ELEMEXTS OF SURGERY. 

take place in the vertebral column ; such as those of the 
head from the first vertebra, and of the first vertebra from 
the second. These, and especially the latter, are the 
most frequent ; but others, though much rarer and more 
diificult, may, hovv^ever, take place. 

The articulation of the occipital bone with the first 
vertebra of the neck is strengthened by means of many 
ligaments, and admits of only very limited motions. It 
is vv^ell known, that the motions of inclination of the head 
to the right and left, and of flexion and extension, take 
place along the whole length of the cervical vertebrae. 
We have no instance of luxation of the head from the 
first vertebrae by an external cause ; such a dislocation, 
if possible, would instantly destroy the individual to 
whom it happened, by the compression and disorganiza- 
tion of the spinal marrow. But nature which cannot 
bear so sudden a change, is habituated to it when it takes 
place gradually and insensibly ; and the spinal marrow, 
which a sudden though inconsiderable derangement of 
the spine would totally disorganize, is not sensibly in- 
jured when it takes place by degrees ; cases of rachitis 
furnish us many proofs of this. It is only in this way 
that we can explain how the individual from whom the 
preparation in the Museum of Natural History was taken, 
could exist until such very great deformity took place in 
his spine. 

It is principally in the triple articulation of these two 
vertebrae, that the motion of rotation of the head to the 
right or left takes place ; for tlie union of the first vete- 
bra to the occipital bone is so close, that the motion of 
both is the same. This rotation of the first vertebra ou 
the second, which the laxity and weakness of the liga- 
ments that go from one to the other, and the direction of 
their articulating apophyses, render easy, would be fre- 
quently carried beyond its natural bounds: and luxation 



ELEMENTS OF SURGERY. ggc 

would take place every time we turn our head with 
force, if the motion were not confined by two very thick 
ligaments, which go from the sides and summit of the 
toothlike process of the second vertebra to the edges of 
the great occipital hole. When this motion is forced 
beyond its proper limits, the ligaments are torn, and the 
lateral parts of the body of the first vertebra glide along 
on the articulating horizontal processes of the second. If 
the head is turned from the left to the right, the left side 
of the body of the vertebra is carried before its corres- 
ponding articulating surface, whilst the right side falls 
behind its corresponding surface. In this luxation, some- 
times the toothlike process, the ligaments of which are 
broken, leaves the ring formed for it by the transverse 
ligament and the anterior arch of the first vertebra, and 
presses on the spinal marrow, the substance of which it 
destroys ; at other times it remains on its ring, but the 
diameter of the vertebral canal is always diminished at 
this place, and the spinal marrow experiences a compres- 
sion, and at the same time a contortion, by which it is la- 
cerated. It is easily conceived that the patient cannot 
survive a derangement of this nature : every lesion of the 
spinal marrow at this height is quickly fatal. Louis, in 
making researches on the manner of dying of hanged 
persons, found that those despatched by the executioner 
of Lyons, perished by the luxation of the first vertebra 
from the second ; whilst those hanged at Paris were suf- 
focated by strangulation. He discovered the cause of this 
difference in a rotatory motion given to the body of the 
culprit by the executioner of Lyons, at the moment that 
the ladder was taken from under his feet. We ought to 
attend to this observation, when we examine in a judi( ial 
capacity the body of a person found hanged. We should 
carefully examine the second vertebra, and see if it be 
luxated. If so the individual has not been guilty of sui- 
VOL. !. 30 



226 ELEMENTS OF SURGERY. 

cide, for the luxation must have resulted from a violent 
motion communicated to the body by the assassin. 

The following case by J. L. Petit, furnishes an in- 
stance of luxation produced by the person himself; the 
circumstances of it are so extraordinary, that we shall 
relate them at full length. 

*^ The only son of a tradesman, aged between six and 
seven years, went into a neighbouring shop, the proprie- 
tor of wliich was a friend of his father's. This person 
playing with the child, put one hand under his chin and 
the other on the back of his head, and then raised him up 
in the air, telling him he was going to shew him his 
grandfather, a common expression among the vulgar. 
Scarcely was the child raised from the ground, when he 
began to struggle, and by his eflPorts dislocated his neck, 
and died on the spot. The father on hearing of the death 
of his child, ran in a fit of passion after his neighbour, 
who fled before him, but not being able to catch him, he 
threw at him a saddler's hammer which he had in his 
hand, and buried the cutting part of it in the depression 
of his neck. The weapon cut all the muscles, pene- 
trated into the space between the first and second cervi- 
cal vertebra, divided the spinal marrow and occasioned 
almost instantaneous death. Thus both perished nearly 
in a similar manner." J. L. Petit, who quotes no 
authority to support this fact, avails himself of the op- 
portunity of censuring this dangerous kind of play, and 
observes with justice, that the motion which the child 
gave himself was the cause of his death. 

The relaxation of the ligaments of the toothlike pro- 
cess may favour this luxation. Such probably was the 
case of a young man, who found a difficulty to bring his 
head back to its natural posture, each time that he turned 
it to the right or left. There are many cases of luxation 
of the neck, in which death does not succeed the acci- 



ELEMENTS OF SURGERY. amm 

dent; but in these the luxation takes place in the 
third, fourth, fifth, or sixth vertebrae, and only one arti- 
culating process is luxated : in these cases, the diameter 
of the vertebral canal is not so much diminished as to 
compress the spinal marrow, and destroy life ; but a wry- 
neck remains, which becomes incurable, unless the real 
cause be found out. 

A child, playing on his mother's bed, suddenly felt 
pain in his neck, accompanied with a distortion which he 
could not remove. Desault, to whom the child was 
brought, discovered a luxation of the vertebrae of the 
neck; but before trying to reduce it, he informed the 
mother that the child might die in the attempt. This in- 
formation terrified the mother so much, that she took the 
child away without having any thing done to relieve it. 

A lawyer writing at his desk, heard the door behind 
him open ; he quickly turned round his head to see who 
was coming in, but could not bring it back again to its 
natural direction. Many surgeons of Paris have seen 
this patient : his head was turned to the right, and slight- 
ly inclined to the shoulder of the same side. This in- 
clination was much less than it would have been in a 
spasmodic contraction of the sterno-cleido-mastoideus 
muscle. 

Thus when in consequence of a sudden and violent ef- 
fort, the head is found turned to one side, either right or 
left, with inability to bring it back, the ear a little inclin- 
ed to one side, and the sterno-cleido-mastoideus in a state 
of relaxation, there can be no doubt but'thata luxation of 
one of the cervical vertebrae has taken place. 

If the luxation produce no symptom which indicates a 
compression of the spinal marrow, it is prudent to abstain 
from all attempts to reduce it. However, if the patient 
absolutely insist on our interfering, we are to proceed in 
this way : we begin by inclining the head to the side 



«gg ELEMENTS OF SURGERY. 

towards which it is directed, in order to disengage the 
articulating process of the upper vertebra : this part of 
the operation is extremely dangerous, as it may kill the 
patient by causing a compression of the spinal marrow. 
When the process is disengaged, the head and neck are 
brought to their right direction, by making them perform 
a rotatory motion the contrary of that which had taken 
place in the luxation. A relapse is prevented by keep- 
ing the head Aee from motion. This is done by means 
of bandages which are attached to the head and shoul- 
ders." (BoYER— Vol. 2.) 



ELEMENTS OF SURGERY. 



CHAPTER XXXVIII. 

Dislocations of the Bones of the Pelvis and Thorax. 

The nature of the articulation connecting the sacrum 
and ossa innominata, and their great strength at the 
places of their juncture, prevent them from dislocation 
except by great violence applied immediately at the spot 
where the synchondrosis exists. The accident in one 
instance occurred by a heavy body falling on the back of 
a labourer, who died twenty days after, and upon dis- 
section a luxation of the sacrum was discovered. The 
right OS ilium passed nearly three inches behind the sa- 
crum and the luxated bones moved freely on each other. 
Great inflammation existed in the parts contained in the 
pelvis, and pus was found in the abdomen. This case 
being very analogous in its symptoms and effects to a 
fracture of the ossa innominata, calls for the same treat- 
ment; rest and the antiphlogistic measures, to guard 
against inflammation. Boyer who relates this case, states 
further, that in pregnant women the symphysis pubis be- 
comes in some cases so much relaxed that the ossa inno- 
minata may be separated, and supposes that something 
similar may take place to a smaller extent at the sacro- 
iUac symphysis. These cases call for no surgical treat- 
ment. 

Dislocations of the os coccygis, may be occasioned in 
early life by the same accidents which at a more advanc- 
ed age, would occasion a fracture. The circumstances 
of the cases bein^ similar, no difference of treatment is 
required. It is evident that luxations of the bones form- 
ing the pelvis have nothing in common with other dislo- 
cations • they are in fact fractures of the cartilage connect- 



330 ELEMENTS OP SURGERY. 

ing these bones ; are produced by the same causes, and 
are to be treated by the same remedies as fractures of the 
bones. They are extremely rare, as the bones generally 
yield and are broken by a force capable of producing the 
dislocation. 

The RIBS likewise, are not capable of dislocation, be- 
cause no force can be applied to their articulation with the 
vertebrae which will not occasion a fracture. 

The starting of the cartilages of the ribs in front is an 
accident which is not unfrequent ; it occurs in certain 
motions of the arm. Mr. Charles Bell observes, " a 
young man playing the dumb bells and throwing his arms 
behind him, feels something give way on the chest ; and 
one of the cartilages of the ribs has started and stands 
prominent. To reduce it, we make the patient draw a 
full inspiration and with the fingers knead the projecting 
cartilage into its place. We apply a compress. and band- 
age, but the luxation is with difficulty retained." 



ELEMENTS OF SURGEBY. g3£ 

CHAPTER XXXIX. 

Dislocation of the Clavicle. 

This is a rare accident compared with the fracture of 
the bone. It occurs at the sternal and also at the hume- 
ral extremity. 

At the STERNAL EXTREMITY the stcmum and the car- 
tilage of the first rib prevent the dislocation downwards, 
but in every other direction it is occasionally dislocated, 
viz. forwards, backwards, and upwards. In general, the. 
displacement is forwards. It is effected by violent mo- 
tions of the clavicle backwards. In consequence of this 
motion the sternal extremity is carried forwards, the liga- 
ments are broken, and the end of the bone is found befor« 
the upper end of the sternum, forming a hard projecting 
tumour, which moves whenever the arm and shoulder are 
moved. 

The treatment of all dislocations of the sternal extre- 
mity, consists in the same dressings as those used for 
fractured clavicle ; they reduce the luxation and main- 
tain the proper situation of the bone. The dressings 
should be continued a greater length of time than in a 
case of fracture ; and in general, some deformity exists, 
the clavicle being more salient than natural at the place of 
dislocation. 

The HUMERAL EXTREMITY of the clavicle is not so 
often dislocated as the sternal. It is generally dislocated 
upward, but it may take place downward, being lodged 
under the accromion. The dislocation upwards is the 
only one demanding attention, because tlie only one in 
which any difficulty is experienced in maintaining the re- 
duction. 



g3S ELEMENTS OF SURGERY. 

The accident is generally occasioned by falling on the 
shoulder, and is ascertained by examination with the fin- 
gers ; the extremity of the clavicle being found under the 
skin covering the accromion, causing a considerable pro- 
jection there. The patient inclines his head to the af- 
fected side, and moves as little as possible the arm and 
shoulder, because he cannot move these parts without 
calling into action the deltoid or some other muscle, whi( h 
would consequently extend the motion to the diseased 
part, and cause pain. 

The treatment of the accident is to be the same as that 
recommended for fractures of the clavicle, viz. the ap- 
paratus of Desault, which effects and maintains, better 
than any other, the reduction. That part of the bandage 
which ascends from the elbow to the shoulder, should in 
the present case be made as tight as can be borne, in order 
to press down the clavicle, and keep it in its proper 
place. 

The inconveniences resulting from this accident whea 
improperly treated are very considerable ; the motions of 
the arm being for a long time greatly impeded ; they are, 
however^, after a lapse of years gradually recovered. 



ELEMENTS OF SURGERY 9^3 

CHAPTER XL. 

Dislocations of the Os Humeri. 

These are by far the most common dislocations, and 
have been supposed to equal in frequency, all others 
which occur.* The structure of the shoulder joint, in 
which a spherical surface is articulated with a very su- 
perficial cavity, and in contact with it in a very few 
points, together with the weakness of the ligaments of the 
joint, and its exposure to violence in performing a great 
variety of motions, are circumstances which sufficiently 
explain the frequency of the accident ; and it would be 
still more frequent, were it not for the admirable provi- 
sion by which the scapula moves with it, thus preventing 
in a variety of instances the force of percussion from act- 
ing solely on the os humeri. Were the scapula fixed as 
is the pelvis, almost every violent motion of the arm would 
be attended with dislocation. 

The head of the os humeri may escape from the gle- 
noid cavity of the scapula in any direction except up- 
wards, where the acromion and coracoid processes and 
the ligament connecting them together, prevent its ascent. 
Mr. Boyer observes, that there is " one species of luxa- 
tion of the humerus of which though it has been described, 
and the possibility made evident, we are not acquainted 
with a single instance, it is the luxation outwards or back- 
wards." Such a case occurred to Dr. Physick in De- 
cember, 1811, and I have seen a luxation directly for- 
wards, the head of the bone being lodged before the co- 
racoid process, both of which will be noticed hereafter. 

The situation of the bone after it has been dislocated 

• At the Hotel Dieu, of the total number of luxations, admitted during a long 
period of time, a majority were luxations of the os humeri. (Bichat.) 
VOL. I. 31 



234 ELEMENTS OF SURGERY. 

IS often changed very considerably by the action of mus- 
cles. 

The dislocation downwards into the axilla, is by far 
the most frequent; the anatomical structure of tlie joint 
has furnished the French surgeons with some ingenious 
reasons for this, but they are of no importance in a prac- 
tical point of view. It is probable that in every case 
where the head of the bone is found in the axilla, a con- 
siderable laceration of the capsular ligament must have 
taken place. 

The symptoms of a dislocation of the os humeri down- 
wards, are very easily distinguished. The principal dif- 
ference observed between the luxated and sound shoul- 
der, are the natural rotundity of the latter, and in the 
injured one a very remarkable depression under the 
acromion which of course appears very prominent ; this 
symptom which was noticed by Hippocrates is never ab- 
sent. The arm is longer than the sound one. Its direc- 
tion is changed, and instead of hanging parallel to the 
side, it stands off at an acute angle from the body, and no 
effort of the patient can draw the elbow close to the side. 
Great pain is perceived in attempting to move the arm in 
any direction, but the motion outwards is less painful than 
any other. The head of the os humeri is felt in the axilla, 
forming a hard round tumour. 

To reduce the bone, a vast variety of means have been 
employed; the ambe of Hippocrates is perhaps the old- 
est apparatus upon record : to recount the different in- 
ventions which have been contrived since his time would 
be a very useless and fatiguing task. I shall therefore 
very briefly describe the method which I believe best 
adapted to the case. It consists in making counter-ex- 
tension against the acromion process of the scapula, and 
extension by the arm above the elbow, the fore- arm being 
flexed. 



ELEMENTS OF SURGERY. gg^ 

If the surgeon is called soon after the accident has 
happened, he is to press firmly with one hand against 
the acromion, and with his other grasping the arm above 
the elbow, forcibly to extend it, the patient being seated. 
In a great number of instances I have known this simple 
inanceuvre to succeed instantly in reducing the bone, the 
strength of an individual being sufficient for the purpose. 

If a greater Tength of time have elapsed, the extension 
and counter-extension are to be made in the same man- 
ner, but with additional power. Several assistants being 
employed, to make counter-extension against the acro- 
mion, by placing one hand over another, and an equal 
number to make extension. 

When the force required is greater than can be thus 
applied, a girth or strong band covered with soft buck- 
skin may be passed over the shoulder for counter-exten- 
sion, and this can be held by assistants, or secured to a 
staple fastened in a wall ; in order to prevent it from slip- 
ping, I have made use of two strips of muslin, one on 
each side of the shoulder, which are passed round the 
band, and held down by an assistant. To make exten- 
sion, a piece of soft buckskin is applied round the arm 
above the elbow, and a strong towel is fastened upon this 
by very numerous turns of a muslin roller passed round 
and round the arm ; to this towel, cords or bands may 
be attached, and any number of assistants can act upon 
them, or if puUies be necessary these can be affixed. 

The advantage derived from the mode of applying 
force ^i^hich has just been recommended is that it acts al- 
most exclusively upon the shoulder joint. When the pa- 
tient is secured by straps, bandages, or jackets about the 
thorax, the scapula moves with the humerus when this is 
pulled, and it would probably be possible to drag off the 
scapula :>nd clavicle together with the arm, without re- 
duciuii: the luxation. T' e mode of treating the accident. 



2S6 ELEMENTS OF SUUGERY. 

by placing the heel in the axilla, and pulling at the arm^ 
is a better plan, for in this case some of the counter-exten- 
sion is borne by the scapula, and this has often been suc- 
cessful, but among the numerous methods which inge- 
nuity has devised to aid in the reduction of a luxated 
humerus, I know of none which so completely and exclu- 
sively operates upon the affected part, and none which can 
succeed more happily than that which I have described.* 

In general, the extension has not been long continued 
in this manner before the head of the bone in the axilla 
is found to move, and very often without any other effort, 
slips into its socket; if this, however, should not be the 
case, the surgeon is to take the fore-arm bent to a right 
angle with the arm, and with some force, rotate it repeat- 
edly inward and outward. If the luxation be not reduced 
thus, pressure against the head of the bone, is to be 
made, directing it towards the glenoid cavity ; if it can 
not now be pushed into its situation, the extensions may 
be suddenly suspended, and the surgeon having his left 
hand under the arm near the axilla, as suddenly depres- 
ses the patient's elbow towards his side and thus uses 
the OS humeri as a lever and brings out the head of the 
bone to a level with the glenoid cavity which it conse- 
quently enters. By these means aided if necessary by 
copious blood-letting, the luxation has in every case I 
have yet seen been reduced. 

Among the causes impeding the reduction of this luxa- 
tion, Desault mentions " a narrowness in the opening of 
the capsular ligament," to enlarge which, he advises 
moving the arm very freely and forcibly in every direc- 
tion. The same measure is useful also by tearing asun- 
der any adhesions which may have formed in the new 
situation of the bone. 

• Mr. Freke, Benjamin Bell, Charles Bell, and other vmters, recommend 
secirring the scapula, but not in the manner here directed. 



ELEMENTS OF SURGERY. ^317 

In all these ejfforts perseverance is an important rule. 
Jff the first attempts fail, they should be repeated, and 
varied again and again, and according to Desault even 
when success is not completely obtained, something will 
be gained if the head of the bone be brought nearer to the 
glenoid cavity, for *' the motions of the bone will be tho 
freer in proportion to its proximity to the natural situa- 
tion." 

At what period after its luxation should we consider 
it impracticable to reduce a dislocated bone ? Did we 
believe B. Bell and other writers of the last century, a 
week or a fortnight having elapsed, all efforts should be 
considered as hopeless. Desault succeeded after three 
months. In a variety of instances Dr. Physick has suc- 
ceeded after two and three months, and Dr. M^Kenzie of 
Baltimore, has replaced a dislocated os humeri nearly 
six months after its luxation. Before answering the 
question therefore, it may be well to consider another 
which I shall state in the language of Dr. Physick, quot- 
ed from his lecture on this subject. " If force applied 
can remove a bone from its natural to an unnatural situa- 
tion, why may not force be so directed as to remove it 
from this new, to its former position ?" If the time could 
be ascertained at which the socket is certainly filled up, 
and its texture completely altered, that would be the time 
to give over all attempts at reduction. 

The plan we have recommended is proper in most 
cases of dislocated os humeri. In the dislocation back- 
ward, (a very rare accident, which neither Desault nor 
Boyer ever saw,) in addition to the extensions and coun- 
ter-extensions, some pressure should be made upon the 
head of the bone, and an attempt to push it towards its 
socket whilst the extension is made. Dr. Physick in 
this manner succeeded in reducing a case of the kind, 
without difficulty. It ^vas distinguished by a great de- 



^38 ELEMENTS OF SURGERY. 

pression under the acromion, as in all other disloca- 
tions ; by a hard tumour on the dorsum of the scapula 
which was evidently formed by the head of the bone ; by 
an inability to move the arm, in any direction ; and by an 
absence of the head of the bone from the axilla. No 
doubt could exist as to the nature of the accident, and no 
difficulty was experienced in its reduction. 

It is astonishing that Mr. Charles Bell should deny 
positively the possibility of this accident. "No force can 
be applied in a direction to dislocate the humerus and 
push its head behind the scapula, for this very evident 
reason that the chest prevents the necessary position of 
the humerus."* Mr. Bell's accurate anatomical know- 
ledge should have taught him that the chest is no defence 
to the shoulder, and that a blow on the shoulder can 
luxate the humerus, as readily as a twist of the arm. In 
the case recited the patient fell through a hatchvvay and 
struck the fore part of the shoulder which was thus push- 
ed directly backwards. 

A case of dislocation inwards and forwards occurred 
to Dr. Physick in 1812 ; there is no reason for believing 
this to have been consecutive, for the head of the bone 
continued unmoved after the accident, and assumed the 
situation in which he found it, immediately after escap- 
ing from the glenoid cavity. As the head of the bone in 
this case, was fixed between the glenoid cavity and the 
coracoid process, extension was made by drawing the 
elbow backwards and downwards, and counter-exten- 
sion, by pressing the acromion scapulje forwards and 
inwards towards the head of the bone, at the same time 
a band was passed under the arm by which the upper 
end of the os humeri was dragged outwards so as to 
unhitch it from the coracoid process. By these means, 

* Operative Surgery, Vol. IT. 



ELEMENTS OF SURGERY. ggg 

after in vain trying extension in the usual way, the 
reduction was eflfected. 

In another instance of luxation forwards and inwards, 
the head of the bone passed completely over the coracoid 
process, and was situated dirertly under the clavicle. In 
this case by bleeding ad deliquium, and extending the 
arm at a right angle from the body, the reduction was 
easily effected. 

After the reduction of a dislocated os humeri the arm 
should be kept at rest, and if inflammatory symptoms 
occur, they are to be treated by the usual remedies. 

Many of the preceding remarks are taken from Dr. 
Physick's MS. lectures. I am well aware that the idea 
of making some counter-extension against the acromion 
is to be found in several writers. Mr. Charles Bell and 
Boyer, appear to come nearer the plan above proposed 
than any others, but their methods are different in many 
particulars : Mr. Hey in his practical observations has 
some excellent remarks on this luxation, but they are 
detailed with less than his usual perspicacity. The great 
object to be kept in view, is to act as effectually as pos- 
sible on the shoulder joint, and this can best be done by 
making the counter- extension as nearly as possible to the 
glenoid cavity, and this can certainly be accomplished by 
making counter-extension exclusively upon the acromion 
process. 

An accidental circumstance which occasioned some 
alarm to Desault in attempting a difficult reduction, it 
may not be improper to notice in this place ; the sudden 
formation of a very considerable tumour at the upper 
pait of the arm, occasioned probably by the rupture of a 
vein, as it subsided in a fortnight, leaving a large 
ecchymosis : no particular injury resulted from it, though 
at first it was mistaken by some, for an effusion of 



g40 ELEMENTS OF SURGERY. 

air from the thorax, and by others, for a rupture of an 
artery. 

The stiffness of the joint which follows a luxation of 
the OS humeri is generally of short continuance, and its 
motions are soon perfectly restored. The arm should be 
gently moved after a few days have elapsed, and these 
motions are to be gradually increased. 



ELEMENTS OF SURGEKY. ^^^ 

CHAPTER XLI. 

Dislocations of the Fore-arm. 

The radius and ulna may be dislocated from the hu- 
merus ; or secondly, The superior extremity of the ra- 
dius may be separated from the ulna ; or thirdly, The 
ulua may be luxated at its inferior extremity from the 
radius. 

1. The articulating surfaces which form the elbow 
joint are very extensive, and the joint consequently pos- 
sesses considerable strength, which is augmented by the 
muscles passing over it and connected with the bones in 
its vicinity. The elbow joint possesses the true hinge- 
like motion, and is a pure specimen of the articulation 
denominated ginglimus. From these circumstances it is 
not frequently dislocated. The luxation may take place, 
however, backwards, and laterally. The luxation back- 
wards is most frequent. A complete dislocation laterally 
f annot take place, from the great extent of the articulating 
surfaces in this direction, and the strength of the muscles 
and ligaments around the joint. 

^' In the luxation backwards the radius and ulna may 
ascend more or less behind the humerus, but the coro- 
uoid process of the ulna is always carried above the ar- 
ticular pulley, and is found lodged in the cavity destined 
to receive the olecranon. The head of the radius is placed 
behind and above the external condyle of the humerus. 
The annular ligament which confines the superior ex- 
tremity of the radius to the ulna may be lacerated, in 
which case even when the bones are reduced, it is diflBcult 
to keep them in their proper places, as the radius tends 
constantly to separate from the ulna. 

VOL. I. 3^ 



24S ELEMENTS OF SURGERY. 

" This luxation always takes place from a fall ou the 
hand ; for when we are falling we are led by involuntary 
instinct to bring our hands forwards to protect the body. 
If in this case the superior extremity instead of restiug 
vertically on the ground, be placed obliquely, with the 
hand nearly in a state of supination, the repulsion which 
it receives from the ground will cause the two bones of 
the fore-arm to ascend behind the humerus, whilst the 
weight of the body pressing the humerus obliquely down- 
wards forces its extremity to pass down before the coro- 
noid process of the ulna. 

^^The fore-arm in this luxation is in a state of deini- 
flexion, and every attempt to extend it, occasions smart 
pain. The situation of the olecranon with respect to the 
condyles of the humerus is changed. The olecraiioB 
which in the natural state is placed on a level with the 
external condyle, which is itself situated lower than the 
internal, is higher than it. 

" This luxation may be mistaken for a fracture of the 
olecranon, of the head of the radius, or even of the lower 
end of the humerus : such a mistake is attended with 
very bad consequences ; for if the reduction be not effect- 
ed before the end of fifteen or twenty days, it is imjjossible 
to accomplish it afterwards.* The swelling more or 
less considerable which supervenes in twenty-four hours 
after the accident, renders a diagnosis diflRcult ; the bony 
prominences are so covered by it, that it is impossible to 
examine their respective situations. Besides, the rub- 
bing of the coronoid process and olecranon against the 
humerus, causes a grating noise similar to that in frac- 
ture. From these circumstances it must appear, that 
much attention is requisite to establish a diagnosis be- 
tween the fracture of the head of the radius, and a dislo- 
cation of the fore-arm backwards." (Boyeu.) 

• This is a great mistake of Mr. Boyer. I have seen a case of this luxatio". 
-which had couthiued longer than a month, very promptly reduccci. 



ELEMENTS OF SURGERY. g^3 

The reduction is effected by seating the patient in a 
chair, and making extension and counter-extension by 
two assistants, one of whom grasps the wrist and the 
other tiie arm near the shoulder. The surgeon now in- 
terlocks his fingers in front of the arm just above the el- 
bow and draws it backwards. If greater force be neces- 
sary it is to be applied in the same directions. Boyer 
recommends that the olecranon be pressed forwards and 
the humerus pulled backwards by the surgeon, who is to 
place the four fingers of each hand on the fore part of the 
humerus, and his thumbs on the olecranon. The only 
objection to the plan is, that the surgeon unless a Her- 
cules, could not in this way act with sufficient power, 
and if the humerus be forcibly dravAn backwards, tliere 
will be no necessity for pushing the olecranon forwards. 
When the reduction is effected, the form and motions of 
the elbow will be restored and a very evident noise will 
be heard at the moment when it takes place. Rest and a 
low diet should be observed for a few days after the ac- 
cident, the fore- arm being preserved in a state between 
flexion and extension by a roller and compresses or 
splints. A week after the accident the arm should be 
gently and repeatedly moved to prevent anchylosis ; these 
motions are to be daily increased, until they are per- 
formed perfectly and without pain. 

" In a luxation of the fore-arm backwards the annular 
ligament which confines the head of the radius to the ex- 
tremity of the ulna, is sometimes torn, and the radius 
passes before the ulna. In such cases, the motions of 
pronation and supination, are difficult and painful, though 
the principal luxation has been reduced.'' The head of 
the radius may be easily replaced by pressing it from be- 
fore backwards, and it is kept in its place by compresses 
bound on the superior and external part of the fore-arm 
by a roller passed round the elbow in form of the 
figure 8. 



g44 ELEMENTS OF SUllGERV. 

When the luxation has not been reduced, the superior 
extremities of the bones, grow to the posterior part of the 
OS humeri, and flexion and extension are thus preduded. 
In young subjects a slight degree of motion is sometimes 
iNigained. 

The lateral luxation, either inwards or outwards, is 
easily detected and easily reduced, the reduction is ef- 
fected by moderate extension, and whilst this is made, by 
pressing laterally the projecting parts of the humerus and 
fore-arm. If no great degree of contusion exists the arm 
requires no dressing, but to be supported in a sling. 

Besides these dislocations the fore-arm may be luxated 
forwards, but in that case, the olecranon process must be 
fractured, and the case, therefore, is to be treated as a 
fracture of the olecranon. The reduction is readily ef- 
fected. 

In all these accidents to the elbow, inflammation su- 
pervenes, and must be remedied by bleeding and a low 
diet. 

2. The head of the radius is in some cases dislo- 
cated from its articulation with the ulna. In general the 
luxation takes place backwards. The hand is found in 
a state of pronation, and cannot be moved out of it with- 
out great pain. The head of the radius is found project- 
ing at the external side of the olecranon. There is a con- 
siderable depression felt at the part where the head of the 
bone is naturally situated. 

To replace the luxated bone, the head of the radius is 
to be pushed from behind forwards, and the hand of the 
patient is at the same time to be brought to a state of su- 
pination. The reduction is thus effected, and an audible 
noise is produced by the re-entrance of the head of the 
radius into the sigmoid cavity of the ulna. The hand re- 
gains the power of rotation ; the ligament in this instance 
being ruptured, it will be some time before the joint re- 



ELEMENTS OF SURGERY. g^ 

covers its motions perfectly, and gentle motion is to be 
frequently made, after the lapse of a few days from the 
accident. The limb may be surrounded at the joint by a 
few turns of a roller, and this may be wet with a saturnine 
lotion. 

3. The inferior extremity of the ulna is occasionally 
dislocated from its connection with the radius. It may 
be pushed either forwards or backwards, most commonly 
backwards. This dislocation is easily distinguished. 
The hand is kept continually in a state of pronation, and 
this position cannot be changed ; a tumour is felt behi7id 
the lower extremity of the radius ; the hand is turned a 
little inwards, and there is an evident depression where 
the lower end of the ulna ought to be situated. The re- 
duction is easily eft'ected, by pulling the arm and turning 
it a little inwards, whilst the lower end of the ulna is 
pushed backwards, and that of the radius forwards, the 
hand being at the same time placed in a state of supina- 
tion. A roller wet with a solution of sugar of lead is to 
be applied after the reduction, and the hand supported at 



rest in a sling. 



The dislocation anteriorly is more rare. It is known 
by the hand being in a continued state of supination and 
it cannot be placed in a state of pronation : a tumour is 
felt before the radius, and there is an empty space where 
the lower end of the ulna should be. The ulna crosses 
the radius obliquely instead of being parallel with it. The 
reduction is efl'ected as the preceding luxation, except 
that the hand must be moved in a contrary direction. 

If the parts be much swollen before the surgeon is 
called, in this as in all similar cases, he should wait un- 
til the inflammation is somewhat abated before making 
any attempt to reduce tlje bone. 



g4-g ELEMENTS OF SURGERY. 

CHAPTER XLIl. 

Dislocations of the Hand. 

^^ Four kinds of luxations may take place in the aiticu- 
lations of the bones of the carpus with the inferior extre- 
mities of those of the fore-arm, viz. luxation forwards, 
backwards, inwards, and outwards. But the two first, 
especially that backwards, are the most frequent, because 
the motions of flexion and extension are much more ex- 
tensive than those of adduction and abduction, and be- 
cause the extent of the articulating surfaces is greater from 
within to the outside, than from before backwards ; be- 
sides, the styloid apophyses of the radius and ulna, 
strengthen the external and internal sides of the articu- 
lation, and render dislocation in the transverse direction 
still more difficult. 

" The articulation of the hand with the fore-arm is re- 
markable in this, that it admits of flexion and extension 
nearly to the same extent ; whilst these two motions, in 
all the other articulations, have rarely the same latitude, 
that of flexion being always the most considerable. 

" Luxation backwards is facilitated by the direction of 
the convex articulating surfaces of the scaphoides, lunare, 
and cuneiforme, which, inclined more backwards than 
anteriorly, must be more disposed to slide in this direc- 
tion than in any other. It is caused by a fall on the back 
of the hand w hile much bent ; in w liich case the first 
range of bones of the wrist slides backwards into the ob- 
long cavity of the two bones of the fore-arm, extends and 
lacerates the posterior ligament, and forms an eminence 
behind the ends of the radius and ulna. This tumour, 
the depression at the anterior part of the wrist, and the 



ELEMENTS OF SUtlGEUY. ^^ 

extraordinary flexion of the hand which cannot be ex- 
tended, are the distinguishing marks of this luxation. It 
is reduced by fixing the fore-arm, and drawing the hand^ 
whilst pressure is made on the eminence formed by the 
displaced carpus to force it back into its cavity. An as- 
sistant fixes the arm, and the surgeon makes extension 
and adjusts the bones. 

Luxation forwards is occasioned by a fall on the palm 
of the hands, the fingers being extended and more force 
being applied to the inferior part of the palm than to the 
superior. It is rarely complete ; the hand remains pain- 
fully extended, and cannot be restored to its natural di- 
rection without some difficulty. The numerous tendons 
which pass before the wrist, and the annular ligament 
which confines them, being piLshed forwards, render it so 
difficult to discover the eminence formed by the bones of 
the wrist before the ends of those of the fore-arm, that this 
affection may be easily mistaken for a sprain. Conse- 
quently, in all doubtful cases, we should proceed as if the 
luxation had really taken place, and bring the hand into 
its proper direction. 

" Luxations backwards, but especially those forwards, 
are always accompanied with a more or less considerable 
laceration of the ligaments, and are followed by an in- 
ilammatory swelling difficult to subdue ; hence, the full 
use of the wrist is not recovered for a considerable time. 
When the bones are reduced, the remainder of the treat- 
ment is the same as in cases of sprain : refrigerants and 
repellents are to be first used, and then emollients and 
resolvents. The patient must not fatigue the hand much, 
even for some time after complete recovery, lest he excite 
inflammation, and lay the foundation of a white swelluig. 
" Luxations inwards, and those outwards, are never 
complete The laceration of the ligaments, a tumour at 
the internal or external side of the joint and distortion of 



^48 elem?:nts of surgery. 

the hand, are the concomitant symptoms of these luxa- 
tions, and mark them out Sufficiently. They are reduced 
by making gentle extension, and causing the two sur- 
faces of the joint to slide on one another in a direction 
contrary to what they took in luxating, and by bringing 
the hand into its natural situation. The danger of these 
luxations depends less on the dislocation than on the 
straining or laceration of the soft parts, which are always 
followed by more or less tumefaction, a symptom difficult 
to subdue, and often the cause of anchylosis or even of 
caries." 

LUXATIONS OF THE RONES OF THE CARPUS AND ME'rACARPUS. 

" The motions of the bones of the carpus and their ar- 
ticulations with one another are so limited, and the con- 
nection is so strong, that a dislocation of them appears 
entirely impossible. However, the head of the os mag- 
num, which is received in a deep cavity formed for it by 
the scaphoides and lunarenaris, may escape from this ca- 
vity, be luxated backwards by too great a flexion of the 
bones of the first range on those of the second, and form 
a tumour on the superior part of the back of the hand. 
Boyer and Desault have both seen cases of this accident. 

^' As to the bones of the metacarpus, they are connect- 
ed so closely and strongly, and support one another so 
firmly in efforts made against the palm of the hand, that 
they are never luxated. The ligaments of their articu- 
lations may, however, be overstretched and torn, and a 
painful diastasis produced, which will require the use of 
emollients and resolvents, with immobility of the hand a- 
long as the affection continues. 

" Notwithstanding the mobility of the articulation of 
the trapezium with the first bone of the metacarpus, the 
latter is luxated but very rarelv. Efforts made in the 



ELEiVfENTS OF SURGERY. g4.g 

thumb which is supported by this bone, would produce 
rather a luxation of the first phalanx, than that of the 
metacarpal bone. The second and third bones are so 
firmly articulated with one another, and with the bones 
of the second row of the carpus, that they are not sus 
ceptible of any luxation whatever. As to the fourth and 
fifth, a little more moveable, and supported by the os un- 
ciforrae, their articulations are more susceptible of sprains 
than true luxations." 

LUXATIONS OF THE FINGERS. 

" The first phalanges may be luxated backwards at 
their articulations with the bones of the metacarpus. A 
luxation of them forwards would be very difficult, if not 
altogetlier impossible, on account of the disposition of the 
articulating surfaces of the metacarpal bones, which are 
much elongated forwards, and allow a great extent of 
motion to the phalanges in this direction, without losing 
contact with them ; and on account of the resistance made 
by the palm of the hand, which would restrain the 
flexion carried beyond what the inclination of the articu- 
lating surfaces would admit of. Luxations inwards can 
take place only in the first phalanges of the thumb and 
little finger : as to that outwards, the first phalanx of the 
thumb alone is susceptible of it. This phalanx is also 
the most exposed to luxations backwards. When a vio- 
lent eflbrt is made on the thumb from before backwards, 
its first phalanx slips behind the head of the first meta- 
carpal bone, and remains extended, while the second is 
bent, its flexor-muscle being thrown into action by the 
irritation. The distortion of the thumb, the impossibility 
of bending the first phalanx, and the pain, render this 
luxation sufficiently evident. 

"The more violent the effort necessary to produce 

VOL. I. -^^ 



g50 KLEMENTS OF SURGEUY. 

these luxations, the more grievous are their conse- 
quences. In some persons in whom the ligaments are 
excessively relaxed, they produce no inconvenience. In 
such, the first phalanx of the thumb may be luxated at 
will ; but then it is as easily reduced as displaced. 

" These luxations should be quickly reduced, for, at 
the end of eight or ten days, they are irreducible. De- 
sault in a case of this kind, proposed making an incision 
behind the superior extremity of the phalanx, and by 
means of it to introduce a spatula, in order to push the 
phalanx into its place ; but the patient frightened at the 
operation, would not submit to it. Citizen Boyer has 
also observed in a hair-dresser, a luxation backwards 
irreducible from having continued too long. 

^^ The reduction is not as easy as one might imagine. 
The number and force of the muscles which are inserted 
into the fii'st phalanx of the thumb, and the little hold we 
can take of this part in order to make extension, render 
the reduction difficult. Luxations of the first phalanges 
of the thumb and little finger inwards, that of the thumh 
outwards, and luxations of the first phalanges of the other 
finger backwards, are all reduced by making extension 
on the inferior extremity of the affected finger, round 
which a fillet is to be passed if there be occasion for 
much force. The wrist is fixed by an assistant, who 
makes counter-extension, and the surgeon replaces the 
bone. The first and second phalanges are also suscepti- 
ble of luxation backwards, which only differs from the 
former by being more easily reduced. After the reduc- 
tion is accomplished a roller is put round the finger to 
prevent a return of the luxation." (Boyer.) 

To the preceding remarks from Boyer I shall add a 
very few respecting the dislocation of the thumb : Mr. 
Hey observes, that " a peculiar difficulty attends the re- 
duction, when the head of the metacarpal bone which is 



ELEMENTS OF SURGERY. ^ai 

joined to the first phalanx of the thumb, is luxated com- 
pletely and depressed towards the palm of the hand. A 
dislocation in the opposite direction, is easily reduced.*' 
Mr. Hey attempts an explanation of the difficulty, from 
the manner in which the lateral ligaments are connected 
with the extremities of the bones concerned in this luxa- 
tion ; these ligaments are connected with the two tuber- 
cles, which are situated on each side of the anterior 
extremity of the metacarpal bone ; upon measuring the 
distance of these tubercles from each other, Mr. Hey 
found " those two, which are nearest the palm of the 
hand, to be three- eighths of an inch from each other, 
while those on the posterior part are distant five-eighths : 
supposing, therefore, the head of the metacarpal bone to 
be pressed forcibly between the lateral ligaments towards 
the palm of the hand, the extremity of the metacai'pal 
bone passes like a wedge between the lateral ligaments, 
and having passed through them, it cannot return, as the 
posterior broad part of the bone presents itself to the 
more contracted aperture between the ligaments. From 
an anatomical consideration of this joint, it seems impos- 
sible that the metacarpal bone should pass in this direc- 
tion to a complete dislocation without tearing off some 
part of the lateral ligaments ; yet so much of the liga- 
ments remains, as to prevent the return of the bone to its 
natural situation.'' 

Mr. Hey himself, experienced great difficulty and was 
foiled in an attempt to reduce this dislocation. He wit- 
nessed also the want of success in other celebrated sur- 
geons, and states on the authority of Broomfield that the 
thumb was actually torn off at the second joint without 
effecting the reduction. Under these circumstances, the 
plan suggested by Desault of cutting open the joint, 
would surely be warrantable, since we know that incised 
wounds of these joints when properly treated seldom 



252 ELEMENTS OF SURGERY. 

occasion any ill consequences. Mr. Charles Bell has, 
however, proposed a plan to which I conceive there can 
be no valid objection in these obstinate cases ; the intro- 
duction of a couching needle obliquely under the skin, so 
as to cut one of the lateral ligaments, this would in all 
probability very quickly liberate the confined bone and 
permit its easy reduction. 

The first case of this accident I ever saw, although 
attended with great difficulty, was eventually reduced by 
Dr. Physick. I have, since the publication of the first 
edition of this work, met with two other instances. The 
first I reduced with great difficulty, the second (in a child) 
very readily. 



ELEMENTS OF SURGERY. ggg 

CHAPTER XLIII. 

Dislocations of the Thigh. 

From a consideration of the structure of the hip-joint, 
in a skeleton, it would appear extremely difficult to effect 
a dislocation of the os femoris, and this difficulty is 
greatly augmented by the cartilages and ligaments con- 
nected with the articulation ; notwithstanding, however, 
these powerful obstacles, the accident not unfrequently 
happens. Mr. Boyer is of opinion, that it is more rare 
than has been supposed, and believes that authors have 
frequently mistaken fractures of the neck of the os femo- 
ris for dislocations. The experience of many practition- 
ers is, however, opposed to the opinion of Boyer, con- 
cerning the comparative frequency of the two accidents. 
So far as my own limited observation has extended, I 
have witnessed about three luxations at the hip, for one 
fracture of the neck of the os femoris.* Mr. Hey says 
he has seen but six cases in a practice of forty-three 
years, during thirty-four of which he attended a large 
infirmary ; this, however, is what few surgeons of equal 
experience can declare. 

The dislocation may take place, upwards and 
backwards (or upwards and outwards) on the dorsum 
ilii ; secondly, upwards and forwards on the os pubis ; 
thirdly, downwards and inwards into the foramen thy- 
roideum; fourthly, downwards and backwards on the 
OS ischium. Some variety exists in the situations of the 

♦ I have had now (1818,) occasion to see this proportion altered, but stiU 
have witnessed many more luxations than fractures. Mr. Astley Cooper states 
the proportion of fractures of the neck of the thigh bone which he has seen 
to be at least four, to one of dislocation. 



254 ELEMENTS OF SURGERY. 

bone in these four kinds of luxation generally described ; 
I have seen a luxation directly forwards, differing some- 
what from the second species, but yet not in any very 
important respect. 1 have also seen a luxation directly 
backwards. 

The most frequent of these accidents are the first and 
third, and of these it is not easy to ascertain the most 
common. The luxation outwards and upwards I have 
met with much more frequently than any other, though 1 
have seen all except the fourth species which is extreme- 
ly uncommon, and perhaps never occurs directly, hut is 
owing to a subsequent change in the position of the head 
of the bone from the action of muscles drawing it down- 
wards. 

A LUXATION UPWARDS AND BACKWARDS is deSCribcd 

very accurately by Boyer. 

^^ When by a fall from a place more or less elevated, 
on the soles of the feet, or on the knees, the thigh is 
pushed forwards and inwards, the head of the femur, 
forced towards the superior and external part of the ace- 
tabulum, breaks the internal and orbicular ligaments, es- 
capes through the laceration in the latter, and ascends on 
the external face of the os ilium ; but as the part of the 
OS ilium immediately above and at the external side of 
the cavity, is very convex, the head of the femur soon 
abandons its first position, and slides backwards and up- 
wards into the external fossa of the os ilium, following 
the inclination of the plane towards this fossa, and obey- 
ing the action of the glutaei muscles which draws it in 
this direction. The head of the femur, in ascending thus 
X)n the external face of the os ilium, pushes upwards the 
glutaeus minimus, which forms a sort of cap for it ; and 
the glutseus maximus and medius are relaxed by the ap- 
proximation of the points into which they are inserted. 
The pyriformis is nearly in its natural state, the gemini^ 



ELEMENTS OF SURGERY. ^55 

obturatores, and quadratus femoris, are a little elongated. 
The psoas magnus and iliacus internus are relaxed, as 
are also the other muscles inserted into the trochanter 
minor. If to this description it be added, that the orbi- 
cular ligament, torn at its superior part, is stretched over 
the acetabulum and covers it, an exact idea may be 
formed of the change occasioned in the surrounding parts 
by this luxation of the femur. The affected thigh is 
shorter than the sound one : it is a little bent, and carried 
iuwards. The knee inclines more forwards and inwards 
than the opposite one ; the leg and thigh are turned in- 
wards, and the foot points in this direction. The tro- 
chanter major is brought nearer the anterior and superior 
spinous process of the os ilium, and is at the same time 
elevated and carried a little forwards ; the latter circum- 
stance may be considered as the necessary consequence of 
the rotation inwards of the thigh. The natural length of 
the limb cannot be restored without reducing the luxation : 
the foot cannot be turned outwards, and any attempt to 
do so causes pain ; but the inclination of the foot inwards 
may be increased. If the patient endeavours to walk, he 
extends the foot to put the top of it on the ground ; and 
though he is raised, he is still lame ; for the diseased 
limb remains always shorter than the other, and the pain 
occasioned by the attempt to walk renders progression 
still more difficult. 

" Luxation of the femur upwards and outwards has 
nothing in common with the fracture of the neck of this 
bone but the shortness of the limb. The easy rotation of 
the member outwards and inwards, &"c. &c. preclude all 
possibility of confounding them, unless tlie surgeon be 
remarkably inattentive. 

" It is difficult to assign the cause of the foot and re- 
mainder of the limb being turned inwards in this luxa- 
tion. It may be established as a general rule,, that luxat- 



g^5 ELEMENTS OF SURGERY. 

ed members always take a direction determined by thfr 
elongation of the muscles of the side opposite that to 
which the luxated bone is carried : thus in luxation of 
the arm downwards and inwards, the deltoides and infra- 
spinatus muscles, lengthened by the separation of their 
points of insertion, move the elbow out from the body, 
and give the arm an oblique direction. In this case, the 
obturatores, gemini, and quadratus femoris, being elon- 
gated, the point of the foot ought to be turned outwards. 
This phenomenon depends perhaps on the external por- 
tion of the orbicular ligament which comes from the an- 
terior and inferior spine of the os ilium; this portion, 
which is very thick, being elongated in the luxation out- 
wards, draws the great trochanter forwards, and conse- 
quently turns inwards the entire limb." 

Luxations of the thigh bone are generally extremely 
difficult of reduction, from the powerful action of the 
muscles surrounding the joint, and from the peculiar con- 
struction of the articulation itself. To effect the reduc- 
tion of the first species of dislocation (upwards and back- 
wards) the patient is to be placed on his back upon a 
table covered with a mattress, or with folded blankets. 
A strong band is to be passed between the pudendum 
and the luxated thigh in such a manner as to press upon 
the ischium, and this band is to be secured firmly to a 
post or staple, or it may be held by a sufficient num- 
ber of assistants; in this manner counter-extension is 
made by fixing the pelvis. The extending force is to be 
made by securing a folded sheet or strong band above the 
knee by means of a roller passed tight round the limb at 
this place; this band is to be delivered to a sufficient 
number of strong assistants. The surgeon directs the ex- 
tension to be made, and with his hands presses upon the 
trochanter and endeavours to direct the head of the bone 
towards the acetabulum. In recent cases this simple 



ELEMENTS OP SURGERY. arm 

plan is often completely successful. The head slips 
into its cavity with a very audible noise, and the symp- 
toms of dislocation immediately cease. 

If this measure, however, should fail, as it sometimes 
does, the head of the bone must be pulled outwards, 
(that is, more remote from the centre of the body.) The 
object of this motion outwards is to raise the head of the 
bone to a level vvitli the high margin of the acetabulum, 
over which it must pass in order to regain its natural 
situation. The means of effecting it are to place the pa- 
tient upon his side, and to pass a band under the thigh ; 
an assistant places his knee upon the crista of the os 
ilium and thus prevents the pelvis from moving in a late- 
ral direction ; the band may be tied over his shoulder by 
which he will be enabled very conveniently to draw the 
thigh outwards; or he may place one foot (without a 
shoe) upon the pelvis, and draw with his hands the late- 
ral band; the extension and counter-extension, as pre- 
viously directed, are to be continued, and the surgeon is 
to bend the leg to a right angle with the thigh, and ro- 
tate tlie limb backwards and forwards. This plan is gene- 
rally successful. A variety of measures have been devis- 
ed by which extension in the directions just described 
may be made, puUies may be substituted for assistants ; 
bed-posts may be used for counter- extension, &c. Nume- 
rous plans suggested by the circumstances of each par- 
ticular patient have been found successful. 

A low diet should be enjoined for several days after 
the reduction of the bone, and the patient should remain 
at rest for a considerable time. The round ligament 
probably never completely unites after this accident, and 
consequently the joint remains always weak. 

The luxation downwards and inwards into the 
foramen thyroideum, is the next in point of frequency. I 
shall quote the description of this accident from Boyer. 

VOL. I. 34< 



358 ELEMENTS OF SURGERY. 

^' It is favoured by the great extent of the motion of ab- 
duction of the thigh; by the notch at the inferior and in- 
ternal part of the acetabulum ; by the weakness of the or- 
bicular ligament at this side ; and lastly, by the situation 
of the round ligament, the rupture of whicli is not a ne- 
cessary consequence of it. It is occasioned by a fall on 
the feet or knees considerably separated from each other. 
The head of the femur slides from without inwards on 
the bottom of the acetabulum, and comes against the in- 
ferior and internal portion of the orbicular ligament, which 
it lacerates and passes on to the foramen ovale between 
the ligament and the obturator externus. 

"In this species of luxation of the femur, the state of 
the soft parts surrounding the articulation is as follows: 
the glutaei, gemini, obturatores, quadratus femoris, psoas 
magnus, and iliacus internus, are elongated by the sepa- 
ration of their points of insertion. The rotation of the 
limb outwards is produced by the elongation of these 
muscles. The adductors, elongated, form at the interior 
part of the thigh a tense cord, which is felt from the pubis 
to below the middle of the thigh. 

" The affected thigh is longer than the sound one ; the 
head of the femur being placed lower than the acetabu- 
lum, the great trochanter is removed to a greater distance 
from the anterior and superior spinous process of the os 
ilium, and the thigh is flattened in consequence of the 
elongation of the muscles. The adductors, extended ob- 
liquely from the pubis to the femur, form a cord which 
elevates the skin of the internal part of the thigh. A 
hard round tumour is felt at the inner and superior part 
of the thigh, formed by the head of tlie femur, which ele- 
vates the soft parts situated before the foramen ovale. 
1 he leg IS slightly bent; the knee and foot turned out- 
wards, cannot be brought back to their proper direction. 
If the patient attempts to walk a few steps, he makes a 



ELEMENTS OF SURGERY. gfjg 

semicircular motion with the foot^ and places at once the 
entire sole on the ground ; and though he keep the knee 
bent, still tlie limb is too long, and occasions lameness. 
The mode of progression of persons whose thigh is luxat- 
ed in this direction may be compared to that of a mow- 
er: — the elongated extremity, like the leg which the 
inovver keeps forwards, describes a semicircular motion 
outwards. 

" All these symptoms taken together form a combina- 
tion too striking to admit of error in our diagnosis, or to 
allow us to confound this luxation with any other, or even 
with fracture of the neck of the femur. 

" The prognosis is somewhat less favourable in this 
than in luxation upwards and outwards. The muscles, 
which might oppose the reduction, being all elongated 
by the very circumstance of luxation itself, renders the 
reduction easier ; besides the contusion of the soft parts is 
less considerable, and the round ligament is stretched, 
but not broken." 

The reduction is to be effected in the same manner as 
that of the luxation last described. 

The luxation upwards and forwards is very rare ; 
Desault describes a case of it, and I had myself an op- 
portunity of seeing a case which Dr. Physick has pub- 
lished. In the latter the luxation was not precisely simi- 
lar to Desault's, the head of the bone being not at all 
higher than the acetabulum. I shall relate this case as 
illustrative of the nature and treatment of the accident. 

"In February 1805, a man was brought to the Penn- 
sylvania Hospital, in consequence of a dislocation of the 
thigh bone at the hip-joint, which had taken place the 
day before in the following manner. As he was riding 
on a sled, which was drawn rapidly along, with his legs 
extended over its side, the foot of his left leg became en- 
tangled in the gears of a team of horses standing in the 



^60 fiLKMENTS Of SUIlGERY. 

road. A great abtluction of the leg and thigh was thus 
suddenly made, by which the head of the bone was forced 
out of its socket, and lodged on the os pubis, directly 
before the acetabulum. In this situation it formed a tu- 
mour, plainly to be seen and felt in the gioin, under 
Poupart's ligament. The foot and knee were turned 
outward, the thigh was extended with the leg bent back- 
ward. By a very particular examination it appeared 
that the dislocated limb was a little longer than the other, 
though the difference in length was very inconsiderable. 

" After an unsuccessful attempt, which is unnecessary 
to describe, the head of the bone was replaced by the fol- 
lowing means. 

" The patient being laid on his back on a table cover- 
ed with a mattress, a firm strap was- placed behind his 
thighs, and the ends of it being carried upwards, before 
and behind his body, were fastened to a staple opposite 
his left shoulder, for the purpose of fixing the pelvis, 
and making the counter-extension. This strap was ap- 
plied in such a manner as to act as much as possible 
against the injured side of the pelvis, and was carried, 
therefore, between the dislocated thigh and scrotum, and 
then over the tuberosity of the ischium of the same side. 
A strong towel was then fastened with a roller upon the 
leg just below the knee, and the leg was bent to a righl 
angle with the thigh. The ends of this towel were tied 
together, and a pulley was hooked to it for the purpose 
of making the extension. 

" In order to draw the head of the bone directly out- 
wards, a firm strap was passed over the pelvis below the 
crista of the ilium of the injured side, and the ends of it 
fastened to a staple opposite the sound side of the pa- 
tient's body. Another strap was applied over the upper 
part of the dislocated thigh, the ends of which were fast- 
ened to a pulley opposite the injured side of the patieui 



FLATE X 




ELEMENTS OF SURGERY. gg^ 

" After the application of this apparatus, before com- 
mencing the extensions, the man was copiously bled, 
with the intention of causing him to faint, an effect, how- 
ever, which was not fully produced, though he lost a 
considerable quantity of blood, by which he was much 
weakened. In this state of debility the extensions were 
repeated, and at the same time the leg being bent, was 
moved inwards and outwards, so as to rotate the thigh 
bone as much as possible and thereby to assist in dis- 
lodging its head. To prevent the abduction of the thigh 
by the strap over its upper part, the knee was pressed 
inwards by the hand of an assistant applied on its outside. 

" In this manner several attempts w ere unsuccessfully 
made, but^ added to the bleeding, they exhausted the 
patient's strength so much, that his body became cover- 
ed with a cold sweat. In this state of weakness the ex- 
tensions were directed to be again repeated with greater 
force than had been before employed, and by these the 
head of the bone was suddenly reduced to its natural 
situation. The patient in a few minutes recovered suffi- 
ciently to move his thigh in every direction, suffered very 
little pain afterwards, and was discharged from the hos- 
pital, cured, in three weeks."* 

In Desault's case the following were the symptoms : 
•• the limb was nearly an inch shorter than natural. The 
point of the foot was turned outwards, the thigh being in 
a state of painful extension could not be flexed on the 
body; adduction and abduction were alike painful; the 
great trochanter being more approximated than usual 
to the anterior superior spinous process of the ilium, was 
also too far forwards; finally, the projecting head of 
the bone could be felt in the groin." The mode of 
reduction which succeeded differed but little from thai. 

• Medical Musuem — vol. 1. 



^Q2 ELEMENTS OF SLRGEliV. 

employed by Dr. Physick, the chief circumstances in 
which the plan of Desault differs from that which we 
would recommend, are that Desault applied extension 
at the ankle, and counter-extension on tlie sound side of 
the pelvis, and not on the side where the dislocation ex- 
isted. Dr. Physick's plan appears calculated to act more 
directly and powerfully on the luxated joint. If the one, 
however, should fail, the other ought unquestionably to be 
tried. 

The luxation downwards and backwards I have 
never seen, and shall quote Boyer's history of it.* 

" Luxation of the femur, downwards and backwards 
may be either primary or secondary. It is primary, 
when in consequence of some effort, the head of the fe- 
mur is forced from the acetabulum at its inferior and pos- 
ti 'or part, and is placed at the junction of the os ilium 
and ischium ; it is secondary, when it succeeds to the 
luxation upwards and outwards, the head of the femur, 
which was placed at first in the external iliac fossa, slid- 
ing downwards and backwards, its passage in this direc- 
tion being favoured by the binding of the thigh on the 
pelvis. 

" In these two cases, the head of the femur rests upon 
that part of the ossa innominata, where the os ilium and 
ischium join. The muscles which cover the posterior 
part of the articulation, such as the pyriformis, gemini, 
obturatores, and quadratus femoris, are raised up and 
stretched ; the psoas magnus and iliacus internus are in 
a great state of tension, and this explains the turning of 
the limb outwards. When this luxation is primary, the 
extremity is lengthened ; a hard tumour is felt at the pos- 
terior and inferior part of the thigh, the great trochanter, 

* Mr. Astley Cooper states, that he has never seen it, and supposes mistakes 
to have arisen on the subject, though he does not positively deny its possibility. 
Surgical Essays, 1818. 



ELEMENTS OF SURGERY. ®gO 

by descending, is removed further from the spine of the 
OS ilium, and the knee and sole of the foot are turned out- 
wards ; but if it be secondary, the thigh is much bent 
against the pelvis ; the knee and sole of the foot are turn- 
ed inwards, because the primary luxation has been up- 
wards and outwards. Secondary luxation in this direc- 
tion is much more frequent than the primary : in reduc- 
ing it, the same rules are to be observed as in other spe- 
cies of luxations.'^ 

A primary luxation directly backwards was brought 
into the Pennsylvania hospital last winter, and after va- 
rious attempts to reduce it by powerful extension, in the 
different directions before described, Dr. Physick thought 
it probable that the head of the bone had slipped through 
a slit or longitudinal rent in the capsular ligament, an-l 
that this rent embraced it at the neck, as a button M^i 
does a button ; under this impression after the extensions 
had ceased, he made an abduction of the thigh, bent to 
a right angle with the body, pushing at the same time the 
head of the bone forwards towards the acetabulum ; this 
manoeuvre in a moment succeeded without any more force 
than the Dr. was himself able to exert — a strong confir- 
mation of his opinion respecting the nature of the obstacle 
previously existing. In all difficult cases it will be proper 
to try every possible motion of the limb, before abandon- 
ing the case as hopeless ; very often after great force has 
failed, a gentle effort in some new direction is found suc- 
cessful. 

Wlien a luxated thigh bone remains long unreduced a 
new joint is formed in the situation where the head of the 
bone is lodged, and a considerable degree of motion is 
regained. The acetabulum lessens in size and is even- 
tually obliterated. When the luxation is upwards and 
backwards an imperfect joint forms on the dorsum ilii, 
and of course the limb is considerably shwtened and the 



364j elements of surgery. 

patient is very lame, walking principally on the toes and 
anterior part of the foot, sometimes he avails himself of a 
high, heeled shoe. If the luxation be forward and down- 
ward the foramen thyroideum forms part of the new articu- 
lating cavity and the limb is rather longer, the patient 
walks much better than in the preceding case. Dr. Wis- 
tar has preserved in his collection very interesting speci- 
mens of new joints formed in consequence of unreduced 
luxations of the os femoris. 

Spontaneous dislocations of the os femoris are those 
in which the head of tlie bone has been protruded by pus, 
granulations, or tumefaction, in the acetabulum. It can 
occur only in cases of extensive disease of the hip-joint, 
and is of little moment compared with the disease of 
which it is a symptom — this we shall describe more par- 
ticularly hereafter. 



ELEMENTS OF SURGERY. ggg 

CHAPTER XLIV. 

Dislocations of the Patella. 

The patella is occasionally forced over one of the con* 
dyles of the os femoris, and is thus luxated laterally. A 
dislocation upwards or downwards cannot take place 
without a rupture of the extensor tendon of the leg, which 
reduces the accident more nearly to the nature of a frac- 
tured than of a dislocated patella, and is to be treated like 
the former case. 

The lateral dislocation is most frequent outwards. The 
patella is found to have deserted the anterior part of the 
knee, and a depression is felt at the place where it is usu- 
ally situated. The internal edge of the patella presents 
anteriorly, the external, posteriorly ; the anterior flat sur- 
face faces outwards, the posterior smooth articulating sur- 
face inwards, being thinly covered ; all these symptoms 
are very obvious. I have known this accident occur in 
dancing : a young lady in attempting some difficult step 
suddenly felt a great pain in her knee, and was unable to 
move it. Dr. Physick was sent for and discovered a luxa- 
tion of the patella characterized by the preceding symp- 
toms ; it was reduced in a moment by extending the leg, 
flexing the thigh on the pelvis, and pushing the luxated 
bone back to its natural situation— a plan which generally 
succeeds very speedily in effecting a reduction of a dislo- 
cated patella. 

In some instances much trouble is experienced in efifect- 
ing the reduction : Sabatier was foiled in attempting it, 
and Boyer who was called in, found great difficulty though 
he eventually succeeded. I have myself experienced much 
difficulty in such a case. A young lady in stepping into 

VOL. I. 35 



g66 ELEMENTS OF SUKGEUY. 

bed dislocated the patella laterally^ and although I saw 
her within five minutes after the occurrence of the acci- 
dent, it occasioned me no small embarrassment. After 
many fruitless efforts I at length succeeded, but not by 
any particular exertion of force or skill, and I cannot de- 
scribe the motion which effected it. 

Sometimes after the reduction, the bone is not easily 
kept in its situation ; in all such cases rest should be en- 
joined, and a bandage, or laced knee cap, should be ap- 
plied, with a compress on the outside of the knee to pre- 
vent the escape of the bone from its central situation. 

When the luxation is inwards the symptoms differ only 
in the situation of the bone. The reduction is effected in 
a similar manner ; a blow on the outside of the knee ge- 
nerally occasions the accident. 



ELEMEXTS OF SURGERY, 



267 



CHAPTER XLV. 

" Of internal derangement of the Knee Joint.^' 

Mr. Hey is the author of some interesting observations 
on an accident which may not improperly be considered 
a species of dislocation. I shall, therefore, quote them 
in this place. 

"The knee joint is so firmly supported on allsidesHby 
tendinous and ligamentous substances, that the bones of 
the thigh and leg are very rarely separated from each 
other, so as to form a dislocation, in the common sensCi 
of the term. Great violence must take place and a con- 
siderable laceration must happen, before the tibia can be 
completely separated from the os femoris. Yet this joint 
is not unfrequently aft'ected with an internal derangement 
of its component parts ; and that sometimes in conse- 
quence of trifling accidents. The disease is, indeed, now 
and then removed as suddenly as it is produced, by the 
natural motions of the joint, without surgical assistance : 
but it may remain for weeks or months, and will then be. 
come a serious misfortune, as it causes a considerable de- 
gree of lameness. I am not acquainted with any author 
who has described the disease or the remedy ;* I shall 
therefore give, such a description as my experience has 
furnished me with, and such as will suffice to distinguish 
a complaint, which, when recent, admits of an easy 
method of cure. 

^* This disorder may happen with or without'contusion. 
In the latter case it is readily distinguished. In the for- 
mer the symptoms are equivocal, till the effects of the 

» I shall presently show that Bromfield was not ignorant of the ewe. 



268 ELEMENTS OF SURGERY. 

contusion are removed. When no contusion has hap- 
pened, or the effects of it are removed, the joint, with 
respect to its shape appears to be uninjured. If there is 
any difference from its usual appearance, it is, that the 
ligament of the patella appears rather more relaxed than 
in the sound limb. The leg is readily bent or extended 
by the hands of the surgeon, and without pain to the pa- 
tient ; at most the degree of uneasiness caused by this 
flexion and extension is trifling. But the patient him- 
self cannot freely bend nor perfectly extend the limb in 
walking ; but is compelled to walk with an invariable 
and small degree of flexion. Though the patient is ob- 
liged to keep the leg thus stiff in walking ; yet, in setting 
down, the affected joint will move like the other. 

" The complaint which I have described may be 
brought on, I apprehend, by any such alteration in the 
state of the joint, as will prevent the condyles of the os 
femoris from moving truly in the hollow formed by the 
semilunar cartilages and articular depressions of the tibia. 
An unequal tension of the lateral or cross ligaments of 
the joint, or some slight derangement of the semilunar 
cartilages, may probably be sufficient to bring on the 
complaint. When the disorder is the effect of contusion, 
it is most likely that the lateral ligament on one side of 
the joint may be rendered somewhat more rigid than 
usual, and hereby prevent that equable motion of the con- 
dyles of the OS femoris, which is necessary for walking 
with firmness.'' 

The mode of cure proposed by Mr. Hey and which he 
found successful in a variety of cases, consisted in plac- 
ing his patient upon an elevated seat having nothing un- 
derneath it which could prevent the leg from being push- 
ed backwards towards tlie posterior part of the thigh and 
then extending the joint by the assistance of one hand 



ELEMENTS OF SURGERY. ^Qq 

placed jast above the knee while with the other hand he 
grasped the leg. During the continuance of the exten- 
sion he suddenly moved the leg backwards that it might 
make as acute an angle with the thigh as possible. Im- 
mediately after this simple operation his patients were 
in general able to walk without much inconvenience and 
the joint soon regained its natural condition. If one trial 
should fail, a repetition of Mr. Hey's method should be 
made. I have seen several cases of this accident in 
which Mr. Hey's plan has been immediately successful, 
a dancing master among others, was twice aflfected with 
this singular and sudden lameness and was very prompt- 
ly cured by a few extensions and flexions of his limb ; 
he began capering immediately after as if nothing had 
happened. 

Mr. Bromfield appears to have been acquainted with 
the accident. ^^ I have seen (he remarks,) a temporary 
lameness happen from one of the semilunar cartilages 
within the joint of the knee, having slipped out of its si- 
tuation ; the knee immediately became swelled, and very 
painful. This case I first discovered by accident; for 
the assistant having hold of the leg, and sometimes lightly 
extending, at other times gently bending it, while I was 
examining the joint of the knee the cartilage slipped into 
its place, and the patient soon became easy. 

" I dare say many surgeons have seen a lameness in 
the shoulder from almost a similar cause, that is, the ten- 
don of the bisceps muscle, which runs in the excavated 
groove at the head of the os brachii, having, by some 
turn of the limb, slipped out of the sulcus, and resting 
on one of the little exuberances of the upper part of the 
channel, till it returned, has occasioned not only an im- 
mobility of the joint, but, most violent pain : when the 
case is known, the reduction is very easy ; for, the cnbit 



gyQ ELEiMENTS OF SURGERY. 

being bent, the muscle is relaxed and while an assistant 
holding the lower extremity of the os brachii, moves the 
head thereof, sometimes inward, sometimes outward in 
the acetabulum scapula, the operator with his fingers will 
easily replace it, and the patient presently becomes per- 
fectly easy."* 

* CUnirgical Observations and Cases, — Vol. 2. 



ELEJVfENTS OF SURGERY. 271 

CHAPTER XLVI. 

Dislocations of the bones of the Leg. 

" The tibia, at its articulation with the condyles of the 
femur, may be luxated in four different directions ; viz. 
anteriorly, posteriorly, and laterally to either side of the 
knee. The luxation backwards is always incomplete ; 
it could not be otherwise without a great laceration of the 
soft parts. It is as often secondary as primary, and in 
such cases it is a concomitant of white swelling, a dis- 
ease much more grievous than the dislocation, and almost 
9,lways requiring amputation. 

" Luxation forwards is still more rare than that back- 
wards ; the ligaments of the knee and the greater part of 
the tendons surrounding it, being placed nearer its pos- 
terior than anterior part, prevent the too great extension 
of the leg. Luxations inwards and outwards are the most 
frequent. They are always incomplete, on account of the 
extent of the articulating surfaces, and the strength of the 
parts surrounding the articulation. They take place 
from the femur being drawn either inwards or outwards, 
while the leg is fixed. 

" The luxation backwards is distinguished by attend- 
ing to the following circumstances : it is impossible to 
extend the leg; the patella, closely applied to the pulley 
of the femur, forms an eminence, under which there is 
an empty space, and the inferior ligament is extended 
obliquely downwards and backwards ; and a projection 
formed by the extremity of the tibia, is felt in the Iiam, 

&:c. &c. 

" Symptoms of an opposite kind accompany the luxa- 
tion forwards. Those inwards and outwards are easily 



27^ ELEMENTS OF SURGERY. 

known from the deformity of the joint. In the first, the 
external condyle of the femur is lodged in the internal 
cavity of the tibia, and the internal condyle projects and 
forms a tumour at the internal side of the knee : the con- 
trary takes place in the second. When they are com- 
plete, which is extremely rare, the tibia is carried en- 
tirely to the internal or external side of the femur. In 
every case of luxation the laceration of the ligamentous 
parts is so great, that the ends of the tibia and femur 
may be easily placed in their natural situations ; there is 
scarcely occasion for even gentle extension and counter- 
extension. It happens sometimes, notwithstanding tlio 
extent of the articulating surfaces, that a return of tlie 
luxation takes place from the great laceration of the 
parts which should confine the bones. To prevent this, 
an apparatus similar to that used in fractures of the thigh, 
is to be applied. Disagreeable symptoms, occasioned 
by the laceration of the soft parts, are always to be ex- 
pected ; our attention should be particularly directed to 
moderate and subdue them. The antiphlogistic regimen 
must be strictly observed, and the other means of pre- 
venting and subduing inflammation had recourse to. If 
the inflammation terminates in suppuration, the abscesses 
are to be opened by making a large incision. In gene- 
ral, large openings are to be made in abscesses seated 
in the neighbourhood of joints to allow a free evacuation 
of the pus, which by stagnating might become acrid, and 
attack the cartilages of the joint ; but if the abscesses be 
formed in consequence of a caries of the ends of the 
bones, a very small opening is to be made, in order to 
prevent as much as possible the inflammation of the 
joint. If the inflammation terminates in gangrene, we 
must wait until nature has arrested the progress of the 
mortification, and then amputate. The separation of the 
living from the dead part, is marked by an inflamed qir- 



ELEMENTS OF SURGERY. g'73 

cle. The progress of the mortification is very often so 
rapid tliat it is impossible to save the patient; and per- 
haps a complete luxation of the tibia from the femur may 
be considered as a case requiring immediate amputation. 
However, before a general precept of this kind can be 
establislied, it must be founded on observations well 
made and judiciously compared. 

" The fibula is difficultly displaced from the tibia, with 
which it forms two articulations ; nevertheless we may 
conceive, that in a violent and sudden turn outwards of 
the foot, if its ligaments are naturally relaxed, it may 
slide from below upwards, so as to touch the external 
condyle of the femur. Citizen Boyer has seen a luxa- 
tion of this kind in consequence of a dislocation of the 
foot outwards. By putting the foot in its natural direc- 
tion, the fibula descended into its proper place. Com- 
presses soaked in resolvent liquids were placed over the 
part, and a roller was passed round the foot and leg, to 
prevent a return of the luxations. The patient had a 
tardy recovery, and some stiffness of the foot remained, 
though the precaution of moving it, when the state of the 
parts would admit it, was not neglected.'' 



VOL. 1, 



S6 



^•74* KLEMENTS OF SLUGElJ i . 

CHAPTER XLVIl. 

Of Dislocations of the Foot. 

" These luxations are but seldom met with ; the great 
violence necessary to produce them and the difficulty of 
ejffecting them, account for their unfrequency. Before 
they can take place, the astragalus must be partially or 
totally forced from the quadrangular cavity formed for it 
by the two bones of the leg, and in which it is received 
like a mortise. The sides of the articulation are strength- 
ened by very strong ligaments, which go from the tibia 
and fibula to the os calcis and astragalus and by the two 
malleoli. An external violence, it is true, may distend 
or even break these ligaments ; but its force being al- 
most entirely spent in producing this efl'ect, will not be 
sufficient to force the astragalus from the cavity in which 
it is enclosed. 

^^ The foot may be luxated inwards or outwards, for- 
wards or backwards, and the luxation in any of these 
directions may be complete or incomplete. Luxations 
inwards and outwards are the most frequent; the former, 
however, occurs more frequently than the latter: the in- 
ternal malleolus not descending so low as the external, 
the astragalus has a less space to describe from without 
inwards, than in the contrary direction. It is occasioned 
by a violent abduction of the foot, and is easily known 
from the derangement of this part, the sole of which is 
turned outwards, and the back inwards ; from the pain, 
and inability of moving the foot; and lastly, by the emi- 
nence formed below the internal malleolus by the astra- 
galus. 



ELEMENTS OF SURGERY. gy^ 

^^ In the luxation outwards, it is equally impossible to 
move the foot; the sole is turned inwards and the back 
outwards, and the astragalus forms an eminence below 
the external malleolus. 

" Luxations of the foot are always dangerous; their 
consequences may be so dreadful as to occasion death, 
and in very many cases tliey render amputation neces- 
sary. However the prognosis is not always so unfavoura- 
ble, for it is clearly proved, that many patients have re- 
covered without any thing extraordinary having occurred 
during their treatment. This invalidates the general 
rule laid down by J. L. Petit to amputate before twenty- 
four hours after the luxation. It is also now well ascer- 
tained that dislocations likely to produce the most mis- 
chievous consequences, have had a happy termination, 
and that this was the case, though the soft parts have 
been very much injured, the ligaments nearly quite rup- 
tured, and the astragalus completely removed from the 
foot. 

" The reduction should be accomplished as soon as 
possible in every luxation of the foot ; if deferred the in- 
llammatory symptoms and swelling which supervene, 
will render it difficult and painful. To effect this, one 
assistant makes counter-extension, by fixing the leg, and 
another draws tlie foot, whilst the surgeon pushes the 
latter part in a direction contrary to that in which it was 
hixaled. If the luxation be inwards, the external edge 
of the foot must be depressed by elevating the internal, 
when it is found that the ligaments yield to the exten- 
sion : the contrary is done in luxations outwards. The 
articulation is covered with compresses moistened with re- 
solvent liquids ; and splints which reach below the sole 
of the foot, are applied on the inside and outside of the leg. 

" Consequences more or less disagreeable are always 
to be expected, whicli may be moderated or even pre- 



gye ELE!krENTS OF SURGERY. 

vented by copious and repeated bleedings. Sometimes, 
notwithstanding the enormous derangement and lacera- 
tion of the soft parts, no bad symptom succeeds, and the 
patient recovers with an unexpected rapidity ; but in very 
many cases, violent inflammation supervenes and quickly 
terminates in gangrene. In other cases the inflammation 
termiiiates in suppuration, abscesses form and heal up, 
and the patient recovers. Sometimes, however, there is 
a caries of the ends of the bones conjoined with them. 

'^ The experienced practitioner is to judge, from the 
nature and violence of the symptoms, w hen immediate 
amputation is necessary. A great number of observations 
posterior to those of J. L. Petit, prove that, by following 
his instructions, we should often amputate a limb which 
miglit be preserved. It is also ascertained by expe- 
rience that the astragalus may be extirpated with advan- 
tage, when the laceration is such, that it is only attached 
by a few shreds of ligament. The tibia, in consequence 
of this extirpation, descends, and rests upon the superior 
face of the os caicis, to which it grows, and the patient 
recovers its use, with an anchylosed joint; but such a 
termination is preferable to losing the foot by amputa- 
tion, or running the risk of the dangerous symptoms 
arising from preserving the astragalus. Ferraud per- 
formed this operation on an invalid soldier, who was in 
the habit of carrying the bone in his pocket. Dcsault 
performed it three times with success. One of his three 
patients (a female) died three months after the operation; 
but she evidently fell a victim to an hospital fever, which 
vras by no means connected with the complaint for which 
she was admitted into the hospital. On dissecting the 
foot, tlie extremity of the tibia was found already par- 
tially attached to the os caicis. There is no doubt but 
ttiat the operation would have been crowned with com- 
plete success, had the person survived tlie other disease. 



ELEMENTS OF SURGERY. gyy 

^* Fractare of the fibula near its inferior extremity, is 
a frequent complication of luxation of the foot inwards. 
This bone is to be carefully examined in all such cases, 
and the foot is to be supported, whether the fibula be 
fractured or not, by means of the ordinary apparatus for 
fractures of the leg. 

" Luxations forwards and backwards, less frequent 
than those described, are, however, sometimes met with. 
The first is occasioned by a fall backwards, while the 
foot is fixed to the ground ; the second by a fall on the 
feet, with the body inclined forwards, and the leg much 
bent. The luxation forwards is more difficultly produc- 
ed than that backwards, on account of the articular pul- 
ley of the astragalus which inclines forwards the poste- 
rior side, being permitted to slide much on the tibia, 
without abandoning it in the extension of the foot. When 
the extension is carried too far, luxation forwards is pro- 
duced." (BOYER.) 

I have known this accident occasioned in the follow- 
ing manner : a lady who wore high heeled shoes, was 
descending rapidly a flight of stairs, the heel of one of 
her shoes hooked itself upon a step, and her whole weight 
was consequently impelled against the anterior part of 
the ankle joint, the foot being fixed by the shoe to the 
step, the tibia was forced forwards, ruptured the capsular 
ligament and was luxated anteriorly. 

" In the luxation backwards, the external and poste- 
rior ligaments, and the posterior part of the capsule, are 
torn ; in that forward, the anterior and external liga- 
ments, tlie anterior fibres of the internal lateral ligament, 
and the anterior part of the capsule are torn. The 
symptoms of the first species are, a diminution in length 
HI that part of the foot between the lower part of the leg 
and tlie anterior extremity of the toes, elongation of the 
heel tension of the tendo acliilles, and relaxation of the 



278 ELEMENTS OF SURGERY. 

entensors of the toes. It is impossible either to bend or 
extend the foot : this symptom distinguishes luxation from 
sprain, in which the foot may be moved, though not with- 
out pain, however high the inflammation may be. 

'' Contrary symptoms accompany the luxation for- 
wards : the foot is lengthened, the heel is shortened, and 
the foot, much extended, cannot be bent, &c. 

^^The reduction of both is easily effected; after which 
it will be necessary to use effectual means to prevent a 
relapse. The mode of treatment, to be afterwards ob- 
served, for subduiugthe unfavourable symptoms that su- 
pervene, is the same as that pointed out for luxations in- 
wards and outwards. When gangrene takes place in 
any luxation of the foot, we must defer amputation until 
its ravages are arrested. In cases where the inflamma- 
tion is moderate, and the destruction of the soft parts not 
considerable, the articulation may be preserved ; and to 
prevent stiffness of the joint, the foot is to be moved as 
soon as circumstances will admit of it. 

^•^The very tliick and short ligamentous substance 
which unites the astragalus to the os calcis, binds them 
so strongly together, that they follow one another in their 
motions, and form as it were but one bone. Hence they 
are never completely separated, even in the most despe- 
rate cases of the luxation of the foot ; but one or both of 
them may be luxated from the scaphoides and cuboides. 
The transverse direction of the articulation formed by 
these four bones, suggested to Chopart the ingenious idea 
of amputating only part of the foot. But these luxations, 
less dangerous than the others, can be occasioned only by 
a violent effort, in which the anterior part of the foot is 
fixed, as happened in the two cases related by J. L. Petit : 
the foot was fastened in an iron grate, whilst the body 
was drawn backwards. The astragalus and os calcis, 
may, under these circumstances, be luxated, but particu- 



ELEMENTS OF SURGEHV. g^Q 

larly the former, the head of which slides from below up- 
wards, in the cavity of the posterior face of the scaphoides, 
and forms a tumour on the back of the foot. The inflam- 
matory swelling renders it often difficult to ascertain this 
luxation. It is not easily reduced, even shortly after it 
has taken place. Citizen Boyer failed in a case of this 
kind, in which the head of the astragalus was luxated up- 
wards and inwards, by a fall from a horse; but after 
some time the person felt no inconvenience from the af- 
fection, he could walk without pain or lameness, and 
nothing remained but the deformity occasioned by the 
tumour. 

" The other bones of the tarsus and metatarsus are too 
strongly tied together to admit of luxation. The pha- 
langes of the toes cannot be luxated by external violence, 
on account of their shortness. However, the possibility 
of luxation of the first phalanx of the great toe from the 
first bone of the metatarsus may be easily conceived. 
It is not necessary to give here the rules to be followed 
in such a case. They consist in reducing tlie luxation, 
and amputating the great toe, when the state of the soft 
parts renders it impossible to preserve it." (Boyer.) 



2SQ ELEMENTS OF SURGERY. 

CHAPTER XLVIIL 

Injuries of the Head. 

Among tlie various accidents which call for the sur- 
geon's aid, none are more important than those to which 
the head is liable ; they in many cases, prove very speedi- 
ly fatal, and always require the greatest attention. 

The scalp is liable to wounds and contusions ; — 
wounds of the scalp have been already noticed, but it 
may be useful to mention on the present occasion, that, 
in addition to the usual effects of blows in which the 
scalp is chiefly concerned, a severe pain sometimes re- 
mains for a great length of time after the accident. 

Dr. Physick describes in his lectures, several cases of 
this singular affection, in which a great variety of means 
were employed without any evident advantage, and in 
which after a lapse of time the pain subsided. In some 
cases, an incision through the scalp at the injured part 
proved immediately successful ; in others, it was found 
entirely inefficient. I know of no remedy for this terri- 
ble complaint which happily is of rare occurrence, but 
which in severity and obstinacy, is surpassed by no local 
pain. Cold-bathing, sea-bathing, mercury, copious bleed- 
ing, blisters, issues, purging, emetics, all the narcotics, 
and numerous other remedies have been used in some in- 
stances without any effect. The incision down to the 
bone should be tried, as it has in some cases produced im- 
mediate relief.* 

• I am very happy to add to this edition, that emetics have been tried by 
Dr. Physick in several cases of this singular malady, with complete success, 
and in tvro instances I also have found them successful. A dose of ipecaciianlia, 
or tartar emetic is to be given every day, till three doses are taken, afterwards, 
once in two or three days, according to the urgency of the case. This practice 
has also effected the cure of several obstinate cases of an analogous disease, the 
tic dcloreux. 



ELEMENTS OF SURGERY. ^f 

A blow on the scalp sometimes occasions an ecchy- 
mosis, in which the blood forming the tumour remains 
fluid, and the surrounding scalp feels unusually hard 
and elevated, and conveys to the fingers a sensation re- 
sembling that of depressed bone. Mr. Pott has described 
this accident particularly, with a view to caution young 
practitioners against opening the tumour under an ex- 
pectation of finding depressed bone. The proper treat- 
ment consists in promoting the absorption of the extra? 
vasated blood by cold applications, and if these are un- 
successful a small puncture may be made with a sharp 
lancet, and the fluid pressed out. If suppuration take 
place, the abscess must be treated in the usual manner. 
It is prudent in all injuries of the scalp to enjoin a low 
diet and prescribe a purge. 

Tlie effects of a blow on the head, owe their chief im- 
portance to the affections of the brain which result. In 
describing these, we shall first notice those cases in which 
the brain is injured hy concussion or contusion; after- 
wards, those cases in which it is compressed by extra- 
vasated blood or a fragment of bone ; and thirdly, pror 
ceed to describe the effects of inflammation. 



vot, I. 



^g CLEMENTS OF SURGERY. 

CHAPTER XLIX. 

Of Concussion of the Brain. 

A PATIENT who receives a violent blow on the head is 
immediately deprived of sense and voluntary motion — ia 
popular language he is stunned. Respiration is per- 
formed slowly, and the pulsations of the heart and arte- 
ries are diminished in frequency. In a lesser degree 
the symptoms are stupidity, drowsiness, imperfect articu- 
lation in speech, diminution in the vigour of all the ani- 
mal functions, nausea, and vertigo. The pupil of the 
eye is generally dilated, at other times contracted, and 
often not at all changed. These effects result from 
blows on the head which occasion fractures of the skull; 
from those in which an extravasation of blood takes 
place within the cranium, — and also from blows which 
produce no fracture and no considerable extravasation. 
It is the latter case which is denominated concussion, 
but whether the symptoms enumerated do ever result 
from accidents which occasion no extravasation, no rup- 
ture of a blood-vessel, no organic lesion in the contents 
of the cranium, I very much doubt. Dr. Physick many 
years ago dissected the brain of a person who died on 
the fifth day after a concussion ; it was found to have 
suffered a contusion; numerous extravasations of small 
quantities of blood, were observed throughout the sur- 
face of the cortical substance of the brain in the vicinity 
of the part stricken, and it resembled a bruise, in every 
respect. Probably the state of the brain after a concus- 
sion is always that of a contusion, — numerous blood- 
vessels of a small size are ruptured, and pour out small 
quantities of blood in various places. 



ELEMENTS OF SURGERY. «,qq 

That we ought to consider concussion as a lesser de- 
gree of compression from extravasated blood, in every 
instance, I am not prepared to assert; but that in all 
cases of violent concussion this bruised state or ecchymo* 
sis of the brain does exist, I have no doubt. The doc- 
trine is by no means novel— Le Dran appears to have 
entertained it to a certain degree, and John Bell also 
advocates it. 

When the brain has suffered concussion merely, the 
symptoms which have been mentioned gradually sub- 
side, the pulse rises to its natural state, the drowsiness 
wears off; sensation is restored, and the functions of the 
body are performed as usual. 

The immediate effects of concussion being over, the 
only ill effects to be dreaded are those which arise from 
inflammation of the brain, and its consequences ; and to 
guard against these is all that is necessary in the treat- 
ment of the case. Cloths wet with cold water should 
be applied to the injured part, and the patient should be 
kept at rest with his head somewhat elevated, during the 
continuance of the stupor; after this has gone off, bleed- 
ing, purging, and a low diet are to be directed, and should 
inflammation supervene, these remedies are to be vigor- 
ously employed according to the exigency of the case. 
Nothing I conceive can be more improper than the use 
of ardent spirits, volatile alkali, and other stimuli which 
have been recommended in cases of concussion of the 
brain. The final cause of the languid circulation which 
succeeds a blow on the head, is probably the prevention 
of extravasation, and yet the officious surgeon attempts to 
interrupt it by stimuli, and thus urges on the action of 
vessels, wounded and bruised by the previous injury 
which consequently pour out an increased quantity of 
blood and produce all the ill effects of compression of the 
brain. 
Mr. Abernethy has described with so much accuracy 



gg^ ELEMENTS OF SURGERY. 

the effects of concussion of the brain, that I shall tran- 
scribe his remarks in this place. " The whole train of 
symptoms following a concussion of the brain, may I 
think, be properly divided into three stages. The first 
is that state of insensibility and derangement of the bo- 
dily powers, which immediately succeeds the accident. 
While it lasts the patient scarcely feels any injury that 
may be inflicted on him. His breathing is difficult, but 
in general, without stertor; his pulse intermitting, and 
his extremities cold. But such a state cannot last long; 
it goes off gradually, and is succeeded by another, which 
I consider as the second stage of concussion. In this 
the pulse and respiration become better, and though not 
regularly performed, are sufficient to maintain life, and 
to diffuse warmth over the extreme parts of the body. 
The feeling of the patient is now so far restored, that he 
is sensible of his skin being pinched ; but he lies stupid 
and inattentive to slight external impressions. As the 
effects of concussion diminish, he becomes capable of re- 
plying to questions put to him in a loud tone of voice, 
especially when they refer to his chief suffering at the 
time, as pain in the head, &c. otherwise, he answers in- 
coherently, and as if his attention could not be excited, 
or was occupied by something else ; he is in short like a 
man in a heavy sleep. The concussion of the brain, 
lastly, produces a state of inflammation of the organ, and 
this constitutes the third stage, which is the most impor- 
tant of the series of effects proceeding from this cause. 

" These several stages vary considerably in their de- 
gree and duration ; but more or less of each will be found 
to take place in every instance where the brain has been 
violently shaken. Whether they bear any certain pro- 
portion to each other or not, I do not know. Indeed 
this will depend upon such a variety of circumstances in 
the constitution, injury, and after-treatment, that it must 
be difficult to determine. 



ELEMENTS OF SURGERY. gQg 

" With regard to the treatment of concussion, it would 
appear, that in the first stage very little can be done. 
From a loose, and, I think, a fallacious analogy between 
the insensibility in fainting, and that which occurs in 
concussion, the more powerful stimulants, such as wine, 
brandy, and volatile alkali, are commonly had recourse 
to, as soon as the patient can be made to swallow. The 
same reasoning which led to the employment of these re- 
medies in the first stage, in order to recal sensibility, has 
given a kind of sanction to their repetition in the second, 
with a view to continue and increase it. 

" But here the practice becomes more evidently perni- 
cious. The circumstance of the brain having so far re- 
covered its powers, as to carry on the animal functions in 
a degree sufficient to maintain life, is surely a strong ar- 
gument that it will continue to do so, without the aid of 
such means ; which tend to exhaust parts already weak- 
ened by the violent action they induce. 

" It seems probable that these stimulating liquors will 
aggravate that inflammation which must ensue sooner or 
later. The access of it in the cases which I have related, 
is sufficiently evident ; and its cure is to be effected by 
the common methods. The great benefit of evacuations 
was, in those cases very evident. Indeed, it appears to 
me, that there is no complaint which requires such means 
to be more rigorously prosecuted, than an inflammation 
of the brain or its membranes. 

"In addition to the reasoning which I have offered 
here, I would observe, that the surgical books abound 
with cases in which suitable evacuations have been free- 
ly employed in concussions, with the best effects; while 
the advocates for a contrary practice, have rested their ar- 
guments upon vague theory, and communicate no parti- 
culars of their success." For the cases referred to in the 
preceding quotation the reader is referred to Mr. Aber- 
nethy's book. 



ggg ELEMENTS OF SURGEUV. 

. CHAPTER L. 

Of Compression of the Brain. 

Compression of the brain may be produced by blood 
extravasated within the cranium, or by a portion of the 
skull being beat in below its natural level. 

OF COMPRESSION FROM EFFUSED BLOOD. 

Blood may be extravasated between the skull and dura 
mater ; — immediately beneath the dura mater ; — ^beneath 
the pia mater ; — ^into the ventricles ; — or into the sub- 
stance of the brain. The symptoms in all these cases are 
similar. It has always been an object of interest among 
surgeons to designate the symptoms which attend com- 
pression of the brain, and to discriminate them from those 
arising from concussion, and although no subject has been 
more carefully investigated than this, yet amidst the mul- 
tiplicity of observations which are to be found in surgi- 
cal writings, no accurately distinctive symptoms have 
ever been pointed out, and this furnishes an argument in 
favour of the opinion that in concussion there is extra- 
vasation.* The loss of sense, speech, and voluntary mo- 
tion, which attends severe concussion, is alike common 
after extravasations of blood, and depression of the skull. 
Mr. Abernethy observes on this subject, that " If we 
judge of the symptoms of compression from what occurs 
in cases of apoplexy, or from cases of the rupture of the 
middle artery of the dura mater, we must be of opinion 

* LeDran long ago observed, that "in concussion small vessels maybe nip- 
tiired and thereby occasion extravasations in several places." Gataker's trans- 
Tut ion — P. 377. 



ELEMENTS OF SURGERY, (ggy 

that pressure on the brain occasions insensibility partially, 
or generally, and in a degree proportionate to its quan- 
tity.'' 

This remark of Mr. Abernethy's is generally, but not 
universally correct, for as Pott observes « sometimes a 
very small quantity of extravasated blood will produce 
the most alarming and most pressing symptoms, and at 
other times a large quantity will occasion none at all.'' 

" In extreme cases the insensibility is manifested by 
every circumstance. The pupil of the eye is dilated and 
cannot be made to contract, even by a strong light. The 
respiration is slow and stertorous, and the pulse propor- 
tionably slow and labouHng. There is no vomiting which 
would indicate sensibility of stomach. The limbs are re- 
laxed as in a person just dead. J^To struggles take place, 
nor signs of sensation appear during the operation, but on 
the pressure being removed sensation and intelligence 
are immediately restored. In concussion the insensible 
state is of short duration and during its continuance the 
body is generally cold, and the pulse feeble and intermit- 
ting. Afterwards the skin is hotter than usual ; the pulse 
and respiration more frequent, the former often intermits, 
and the latter has not the stertor of apoplexy (but the ab- 
vsence of stertor must not be relied on as a proof that there 
is no compression, for Morgagni relates dissections of 
apoplectic persons where the effusion was considerable, 
yet no stertor had occurred, and I have seen cases where 
it took place only in a very slight degree.) The pupil of 
the eye is not dilated, but rather contracted. The coun- 
tenance expresses pain and uneasiness, and vomiting oc- 
casionally takes place. The state of the patient is like 
that of a heavy and uncomfortable sleep ; yet being 
roused, signs even of intelligence appear." These re- 
marks of Mr. Abernethy contain the best contrast of the 
symptoms resulting from concussion and compression 



g88 ELEMENTS OF SURGERY. 

which are to be found, but in some cases they arc insuf- 
ficient to afford an accurate diagnosis. 

In many instances, however, the symptoms indicating 
extravasation are very clearly marked ; of a great num- 
ber of cases which I have met with in books and in prac- 
tice, I shall relate the prominent circumstances of one, to 
illustrate this observation. 



CASE. 



On the tenth of May 1811, Michael Schoch, aged 
about forty years, in ascending the first step of a stair- 
case fell backwards on the floor ; he arose, rubbed his 
head, and did not suppose himself much hurt. About 
twenty minutes after the accident, he felt sick at the sto- 
mach and vomited. In half an hour he became drowsy 
and stupid, his stupor gradually increased, and when I 
saw him, which was several hours after the accident, he 
was perfectly senseless and could not be roused. His 
breathing was stertorous, his pulse about forty, and com- 
municated to the fingers the same sensation^ as that of a 
patient in apoplexy. 

Upon shaving the head, not the slightest vestige of in- 
jury could be observed. From these circumstances it was 
very obvious that a blood-vessel was ruptured within the 
cranium. His brother said that he had pointed to the 
left side of his head above the ear, after his fall ; and with 
no other direction than this, as to the part injured, I re- 
solved to perforate the parietal bone, and accordingly cut 
through the scalp and applied the trephine ; immediately 
on removing the bone a large quantity of blood escaped 
at the opening, and upon passing my finger under the cra- 
nium, I was literally unable to feel the dura mater ; clots 
of blood appeared to occupy the place of the whole left 
hemisphere of the brain, the quantity of blood extra- 



ELEMENTS OF SURGERY. ggn 

vasated was very great; far exceeding any thing I had 
conceived possible. 

Copious extravasations always happen when one of 
the principal vessels of the dura mater is ruptured, but 
when this membrane is merely separated from the skull 
by the accident, and the only vessels divided, are those 
which connect the bone and membrane, then the quan- 
tity effused is comparatively small supposing the middle 
artery of the dura mater to be opened in the present in- 
stance. 

I determined to make another perforation with the 
trephine, and then trust the case to copious bleeding and 
purges. I accordingly enlarged the incision of the scalp, 
and now discovered a small fissure an inch long in the 
parietal bone, (which probably was in itself of no im- 
portance) without any depression ; the greater part of 
this crack was included in the second portion of bone 
which I removed. In a few hours the stupor subsided 
aad the pulse rose. The patient was copiously and re- 
peatedly bled, and for three weeks nourished exclusively 
by toast and water; the blood for the first week came 
away in large quantities through the openings in the 
skull, and afterwards blood and matter came out to- 
gether. This patient soon recovered and has remained 
perfectly well for two years, except that he is afflicted with 
a periodical head-ach with which for many years he has 
been troubled, and which has recurred since the accident. 
His right side was slightly paralytic for a day or two 
after the operation, but no permanent affection of that 
nature remained. Mr. Hill relates a case very similar 
to this, and Mr. Latta also records one not unlike it. 

In the preceding case, as in many other instances of 
extravasation, the patient remained well for a considera- 
ble space of time ; this was owing to the gradual accu- 
mulation of the blood which did not immediately collect 

VOL. I. 38 



5^90 ELEMENTS OF SURGERY. 

in sufficient quantity to occasion stupor. Patients often 
walk to a considerable distance before any symptoms of 
compression appear. In every case, therefore, when 
after the blow, the patient remains a considerable time 
free from stupor, we may conclude without much risk of 
mistake that extravasation has happened, or if the patient 
be stunned by the blow and recover from tliis first efifect 
of the violence, and regain his senses, and after this in- 
terval of sense, relapse into a stupid comatose state ; we 
have also great reason to apprehend extravasation. 

It has already been observed that the situation of the 
effused blood varies. In general, however, indeed in a 
very large majority of instances, the extravasated blood 
is found between the dura mater and the skull, owing to 
the intimate connection by means of vessels between this 
membrane and the bone. In every case, therefore, where 
there is good reason to believe that extravasated blood 
exists under the skull, it is the duty of the surgeon to re- 
move a portion of the bone in order to allow its escape. 

In endeavouring to ascertain the part of the head where 
this extravasation will probably be found, all the circum- 
stances of the accident are to be carefully considered. The 
head being shaved, a bruise or wound may generally be 
discovered at the injured part, and if so, the crown of the 
trephine should be applied at that part. If, however, (as 
sometimes happens) no part of the head appears to have 
suffered more than another and the witnesses of the acci- 
dent can give no account of the spot which received the 
blow, still should the symptoms continue to indicate the 
operation, it ought to be performed, and the part where 
extravasations most generally happen, should be select- 
ed ; perforations may in such cases with great propriety 
be made in the course of the middle artery of the dura 
mater, and if the extravasation be not found here the 
operation should be repeated on the opposite side of the 



ELEMENTS OF SURGERY. gg^ 

head, over the same vessel. If paralysis of one side of 
the body exist, it affords a presumption that the opposite 
side of the head has suffered. 

In attempting to ascertain the place of extravasation, 
Mr. Abernetliy recommends to scrape the bone where 
the mischief is suspected, if it bleed, there will be no rea- 
son to expect an effusion under it, if no blood escape 
from the bone when scraped, it is an evidence of extra- 
vasation underneath. This trulv in2;enious idea was 
suggested to Mr. Abernetliy, in reilectiug on the vascu- 
lar connection subsisting between the dura mater and 
skull ; a great part of the blood of the skull is derived 
from the dura mater, and if the connection be destroyed, 
there is a deficiency in the quantity of blood which the 
bone receives. Mr. Abernethy has in two instances by 
attending to this rule, ascertained the extent to which 
the dura mater and skull were separated by extrava- 
sation.* 

Oq removing a portion of bone the blood if fluid imme- 
diately escapes ; in most instances, however, a considera- 
ble portion of it will be found coagulated. The dura 
mater being separated from the cranium to an extent pro- 
portioned to the quantity effused, the coagula if it can 
readily be done should be removed, but care should be 
taken not to injure the dura mater by introducing any in- 
struments for the purpose, it is safer to trust to the ac- 
tion of the brain, which will effectually expel these coa- 
gula. In cases where the quantity of blood found under 
the cranium is very great, two perforations may be made, 
or perhaps cases may occur w here a greater number will 
be necessary, but from what I have seen of such cases, 

• I have myself been less fortunate, and Dr. Parrish has recently put the 
matter fairlv to tlie test in a case of very copious extravasation. In this in- 
stance the parietal bone was detached from all its membranous connexions 
to a considerable distance, and yet bled freely when scraped. 



gg^ ELEMENTS OF SURGERY. 

and from similar ones contained in the memoirs of the 
French academy, I am disposed to believe that an exten- 
sive removal of bone in cases of extravasation is im- 
proper, the brain does not immediately react, and the pa- 
tient expires in some instances before the operation is con- 
cluded. The case I have detailed in the present chap- 
ter, is a convincing proof of the power of the brain to 
evacuate the clotted blood even when it exists in the 
largest quantities. 

In some instances when a portion of the bone is re- 
moved by the trephine, the dura mater is protruded up 
into the orifice forming an elevated tumour evidently con- 
taining blood ; in these cases it has been recommended to 
puncture the membrane and evacuate the fluid. Of the 
propriety of this practice I have great doubts. Dr. Phy- 
sick has witnessed the operation in several cases, all of 
which terminated fd^tally, and Mr. Abernethy states that 
in those cases which he has seen " where blood was ex- 
travasated between the dura and pia mater and a division 
of the former membrane was made for its discharge, in 
some instances the serous part only could be evacuated ; 
for the coagulum was spread over the hemisphere of the 
brain, and had descended as low as possible towards its 
inferior part ; in others, though a portion of the effused 
blood was discharged in a fluid or grumous state, a con- 
siderable quantity which was coagulated remained behind, 
so that very little relief was obtained by the operation. 
It seems then, that extravasation between the dura mater 
and the cranium is almost the only case of extravasion 
which admits of being remedied by the use of the tre- 
phine." 

Cases have occurred, and some such are recorded, 
where punctures through the dura mater have been made 
for the evacuation of blood, and a favourable termination 
has resulted ; these cases are, however, extremely rave, 



ELEMENTS OF SURGERY. 203 

and a fatal event in most instances results. The reco- 
veries which happen after wounds of the dura mater, are 
by no means analogous ; because, in these the membrane 
is not detached from its usual connexions, and is unin- 
jured except at the wounded part; whereas in cases 
where it is punctured for the purpose of evacuating either 
cxtravasated blood or pus, it is separated from every at- 
tachment to the skull and pia mater to a very considera- 
ble extent ; under such circumstances it generally sloughs, 
and when this happens, the brain beneath inflames and 
suppurates, and death is the consequence. I believe the 
best general practice in cases of extravasation beneath the 
dura mater, whether immediately under it, or in the ven- 
tricles, or in the substance of the brain, will be to bleed 
copiously and as often as the patient's strength can per- 
mit. To administer purges daily, to prohibit all nourish- 
ment except bread and water, and to apply blisters over 
the head. 

Under this mode of treatment, I have witnessed reco- 
veries where there was every reason to believe that con- 
siderable effusions of blood existed under the dura mater, 
and I have never seen success attend any other method, 
though I have full confidence in the testimony of others 
who have been more fortunate. Mr. Abernethy for in- 
stance, relates a case in which one of his pupils evacuated 
five ounces of blood through a puncture in the dura mater 
and cured the patient. — Here the case was recent, the 
blood was still flowing from the wounded vessel, and all 
the circumstances of the case were as favourable as possi- 
ble, and under such circumstances the operation may be, 
and ought to be performed : that is to say, the dura mater, 
should he punctured whenever fluid, fresh blood, pushes 
it out so as to form a tumour in the aperture made hy 
the trephine, provided the symptoms are also indicative 
of pressure on the brain to a great degree. 



gj)4? ELEMENTS OF SURGERY. 

OF COMPRESSION OF THE BRAIN FROM DEPRESSED BONE. 

Fractures of the skull as tliey are produced in a va- 
riety of ways, must differ very materially in their nature 
and extent. The numerous divisions of the ancients, 
founded upon these circumstances are, however, of little 
importance. The chief differences now regarded, are 
the degree of pressure and irritation produced upon the 
brain and its membranes. 

Fissures or cracks in the skull unattended by a de- 
pression of one of the fragments are not dangerous, and 
very readily heal without unpleasant symptoms ; but 
pressure from a piece of bone beat down upon the brain 
must occasion all the symptoms which are produced by 
pressure from an effused fluid : accordingly we find that 
patients thus circumstanced are generally affected with 
the same apoplectic symptoms, — a complete or partial 
loss of sense, speech, and voluntary motion — stertorous 
breathing, followed by vomiting, vertigo, hemorrhage 
from the ears, nose, mouth, &c. Now these symptoms 
often occur without a fractured skull, as has already 
been remarked, and on the other hand, many cases of 
fractured skull, even where the bone is considerably de- 
pressed, are unaccompanied by them. I once saw a wo- 
man who had been assaulted by a lunatic, and struck 
forcibly with an iron bar : I found her skull fractured near 
the junction of the parietal bones, a depression existed 
which in one part was full half an inch below the natural 
level, and yet none of the usual symptoms of compressed 
brain occurred, and the fracture healed up without any 
dressings except a superficial pledgit. Similar cases are 
recorded. 

Fractures of the skull although they occasionally pro- 
duce no unpleasant symptoms, are notwithstanding, ac- 



ELEMENTS OF SURGERY. ggg 

companied with many clangers. In addition to the evils 
to be dreaded from pressure upon the brain, the irritation 
occasioned by the mechanical action of the sharp and ir- 
regular edges of the bone upon the dura mater and brain 
is to be feared. The constant pulsation of the vessels of 
the brain, which produces motion under the fracture, 
augment considerably the irritation in consequence of 
which the dura mater sometimes ulcerates. 

In many cases of fracture of the skull the dura mater 
is pierced and the brain wounded, by the body which 
caused the accident, or by a fragment of the bone being 
forced through these parts. In some instances portions 
of the substance of the brain escapes through the frac- 
ture at the time of the accident. In sabre wounds, slices 
of brain, together with considerable portions of skull are 
sometimes removed. 

To ascertain the existence of a fracture of the skull, 
the bone must be laid bare and examined. In general, 
the part which received the blow is fractured, but some- 
times the skull suffers in a remote situation, in conse- 
quence of what the French surgeons have called a contre- 
coup ; very good proof exists that fractures have been 
thus occasioned by counter- strokes, on the opposite side 
of the skull. If a wound of tlie teguments accompanies 
the accident, the fracture is often obvious on the first ex- 
amination. If the wound be too small to afford a view 
of the skull, or if only a contusion exist, it is easy with 
a scalpel to cut down to the bone and expose it sufficient- 
ly. This, however, should never be done unless symp- 
toms of compressed brain exist, because the exposure 
converts the injury to a compound fracture, and greater 
inflammation is therefore to be expected, from which pos- 
sibly the dura mater and brain may suffer. 

Respecting the treatment of fractured skull, a variety 
of opinions exist among surgeons. The practice I would 



296 ELEMENTS OF SURGERY. 

recommend I shall briefly state. In every instance where 
symptoms of compression exist, whether these arise from 
fracture or from extravasated fluids a perforation ought 
to be made through the skull by means of a trephine, at 
the spot where such pressure is reasonably judged td 
exist. The immediate effects of concussion of the brain, 
generally subside in a few hours, and as these may be 
supposed to exist in all cases of injured brain, it will 
(except in particular instances presently to be noticed) 
be proper to defer the operation, until such effects shall 
have subsided. If then it be found after waiting twelve 
hours,* that evident symptoms of compression exist with- 
out abatement, the operation should be no longer delayed, 
but the fracture sought for, and if depressed bone be found 
it should be elevated, and all loose fragments removed. 
If a crack or fissure only be found, still the symptomi 
existing, a perforation should be made to discharge the 
blood which is probably effused under it. 

The particular cases in which the operation should 
be promptly performed, are those in which the extent of 
injury leaves no doubt as to the existence of fracture with 
depression, and where there can be no probable expec- 
tation that the symptoms will subside when the imme- 
diate effects of concussion are over. A man is thrown 
from his horse head foremost upon a stump or on a stone, 
and the surgeon on his arrival finds an extensive frac- 
ture, with depression, and all the symptoms of compres- 
sed brain — in such a case it is right to perform the ope- 
ration immediately. 

Should depressed bone be removed, or the operation 
of trephining ever be performed to prevent the ill conse- 

♦ This is a very general direction, and of course many exceptions will be 
made to it, as the effects of concussion subside in some cases much sooner 
than in others,— whenever a doubt exists, postponement is the preferable plan. 
Mr. Abernethy and Mr. John Bell, both sanction this practice. 



ELEMENTS OF SURGERY. ggy 

queuces of inflammation of the brain? Mr. Pott under 
particular circumstances, recommended the practice, — 
Mr. Aberncthy, however opposes it, and Mr. John Bell, 
Desault, and many modern surgeons, deny that it is ever 
proper, and assert that the trephine is only to be applied 
with a view of relieving present symptoms. I have never 
seen reason to differ from this opinion, and though cases 
may be imagined where the trephine would certainly 
prevent fatal consequences, yet in practice, such certainty 
is seldom evident. It would be improper in a compendi- 
ous work like the present to enter into any discussion on 
this question : I shall therefore conclude this part of the 
subject by recommending to postpone the operation of 
trephining in all cases where doubt exists as to its pro- 
priety, because in many cases it will be found, that when 
inflammation moderates, the symptoms of compression 
will be diminished by the diminution of fullness in the 
vessels, and if the operation be indicated afterwards it 
can still be performed, and perhaps with as good a pros- 
pect of success. 

OF INFLAMMATION OF THE BRAIN AND ITS MEMBRANES FROM 
EXTERNAL VIOLENCE. 

Mr. Abernethy very judiciously remarks, that " in the 
generality of cases of injury done to the head, the symp- 
toms of concussion, compression, and inflammation, are 
so combined as to appear inexplicable. It is only by 
an attention to those rare cases, in which the symptoms 
of each appear distinctly, that we are likely to increase 
our knowledge of their specific effects." Inflammation of 
the brain and its membranes is a consequence of differ- 
ent species of violence to which it is subject, and there- 
fore, its symptoms will be more or less blended with those 
resultin"- directly from the accident, as stupor, &c. In 

VOL. I. 39 



2gS ELEMENTS OF SURGERY. 

describing the inflammatory symptoms which occur, I 
shall principally avail myself of the descriptions given by 
Mr. Pott and Mr. Abernethy. The inflammation op 
THE DURA MATER Is wcU described by the first of these 
writers. 

^•' If there be neither fissure nor fracture of the skull, 
nor extravasation, nor commotion underneath it, and the 
scalp be neither considerably bruised, nor wounded, the 
mischief is seldom discovered or attended to for some 
few days. The first attack is generally pain in the part 
w^iich received the blow. Th» - pain, though beginning 
in that point, is soon extended all over the head, and is 
attended with a langour, or dejection of strength and spi- 
rits, which are soon followed by a nausea and inclina- 
tion to vomit, a vertigo, or giddiness, a quick and hard 
pulse, and an incapacity of sleeping, at least quietly. A 
day or two after this attack, if no means preventative of 
inflammation are used, the part stricken generally swells, 
and becomes puffy and tender, but not painful; neither 
does the tumour rise to any considerable height, or 
spread to any great extent : if this humid part of the 
scalp be now divided, the pericranium will be found of a 
darkish hue, and either quite detached, or very easily 
separable from the skull, between which and it, will be 
found a small quantity of a dark-coloured ichor. 

^^ If the disorder has made such progress, that the 
pericranium is quite separated and detached from the 
skull, the latter will even now be found to be somewhat 
altered in colour from a sound healthy bone. Of this 
alteration it is not easy to convey an idea by words, but 
it is a very visible one, and what some very able writers 
have noticed. 

"From this time the symptoms generally advance 
more hastily and more apparently ; the fever increases, 
the skin becomes hotter, the pulse quicker and harder, 



ELEMENTS OF SURGERY. ggg 

the sleep more disturbed, the anxiety and restlessness 
more fatiguing, and to these are generally added irregu- 
lar rigors, which are not followed by any critical sweat, 
and which instead of relieving the patient, add consider- 
ably to his suffering. If the scalp has not been divided 
or removed, until the symptoms are thus far advanced, 
the alteration of the colour of the bone will be found to 
be more remarkable ; it will be found to be whiter and 
more dry than a healthy one, or, as Fallopius has very 
justly observed, it will be found to be more like a dead 
bone : the sanies or fluid, between it and the pericranium, 
will also, in this state, be found to be more in quantity, 
and the said membrane will have a more livid diseased 
aspect. 

" In this state of matters, if the dura mater be denuded, 
it will be found to be detached from the inside of the 
cranium, to have lost its bright silver liuc, and to be, as 
it were, smeared over with a kind of mucus, or with 
matter, but not with blood. Every hour after this pe- 
riod, all the symptoms are exasperated and advance with 
hasty strides : the head-ache and thirst become intense, 
the strength decreases, the sighs are more frequent, and 
at last convulsive motions, attended in some with delirium, 
in others with paralysis or comatose stupidity, finish the 
tragedy. 

" If the scalp has not been divided or removed till this 
point of time, and it be done now, a very offensive disco- 
loured kind of fluid, will be fouiul lying on the bare cra- 
nium, whose appearance will be still more unlike to the 
healthy natural one ; if the bone be now perforated, mat- 
ter will be found between it and the dura mater, generally 
in considerable quantity, but different in different cases 
and circumstances. Sometimes it will be in great abund- 
ance, and diffused over a very large part of the mem- 
brane : and sometimes the quantity will be less, and con- 



^QQ ELEMENTS OF SURGERY. 

sequently the space which it occupies smaller. Some- 
times it lies only on the exterior surface of the dura mater ; 
and sometimes it is between it and the pia mater, 
or also even on the surface of the brain or within the sub- 
stance of it. 

" The primary and original cause of all this, is the 
stroke upon the skull ; by this the vessels which should 
carry on the circulation between the scalp, pericranium, 
skull, and meninges, are injured, and no means being 
used to prevent the impending mischief, or such as have 
been made use of, proving ineffectual, the necessary and 
mutual communication between all these parts ceases, the 
pericranium is detached from the skull, by means of a 
sanies discharged from the ruptured vessels, the bone be- 
ing deprived of its due nourishment and circulation, loses 
its healthy appearance, the dura mater (its attaching ves- 
sels being destroyed or rendered unfit for their office) se- 
parates from the inside of the cranium, inflames and sup- 
purates. 

^* Whoever will attend to the appearances, which the 
parts concerned make in every stage of the disease, to 
the nature of the symptoms, the time of their access, their 
progress, and most frequent event, will find them all easi- 
ly and fairly deducible from the one cause, which has 
just been assigned, viz. the contusion. As the inflamma- 
tion and separation of the dura mater, is not an immediate 
consequence of the violence, so neither are the symptoms 
immediate, seldom until some days have passed; the 
fever at first is slight, but increases gradually ; as the 
membrane becomes more and more diseased, all the fe- 
brile symptoms are heightened ; the formation of matter 
occasions rigors, frequent and irregular, until such a 
quantity is collected, as brings on delirium, spasm, and 
4eath. 

^'Hitherto I have considered this disease, as unac- 



ELEMENTS OF SURGERY. 3Qj[ 

companied by any other, not even by any external mark 
of injury, except perhaps a trifling bruise on the scalp; 
let us now suppose the scalp to be wounded at the time 
of the accident, by whatever gave the contusion ; or let 
us suppose, that the immediate symptoms having been 
alarming, a part of the scalp had been removed, in or- 
der to examine the skull ; in short, let the injury be con- 
sidered as joined with a wounded scalp. 

" In this case, the wound will for some little time have 
the same appearance, as a mere simple wound of this part 
unattended with other mischief, would have ; it will like 
that, at first discharge a thin sanies or gleet, and then 
begin to suppurate ; it will digest, begin to incarn, and 
look perfectly well ; but, after a few days, all these fa- 
vourable appearances will vanish ; the sore will lose its 
florid complexion, and granulated surface ; will become 
pale, glassy, and flabby ; instead of good matter, it will 
discharge only a thin discoloured sanies ; the lint with 
which it is dressed instead of coming off easily (as in a 
kindly suppurating sore) will stick to all parts of it ; and 
the pericranium instead of adhering firmly to the bone, 
will separate from it, all round, to some distance from the 
edges. 

" The first appearance of alteration in the wound im- 
mediately succeeds the febrile attack, and as the febrile 
symptoms increase, the sore becomes worse and worse, 
that is, degenerates more and more from a healthy, kind- 
ly aspect. 

^^ Through the whole time, from the first attack of the 
fever, to the last and fatal period, an attentive observer 
will remark the gradual alteration of the colour of the 
bone, if it be bare. At first it will be found to be whiter, 
and more dry, than the natural one ; and as the symp- 
toms increase, and either matter is collected, or the dura 
mater becomes sloughy, the bone inclines more and more 



2Q^ ELEMENTS OF SURGERY. 

to a kind of purulent hue, or whitisli yellow ; and it may 
also be worth while to remark, that if the blow was on 
or very near to a suture, and the subject young, the said 
suture will often separate in such a manner as to let 
through it a loose, painful, ill-natured fungus ; at which 
time also it is no uncommon thing for the patient's head 
and face to be attacked with an erysipelas." (Pott.) 

The piA MATER is often attacked with inflammation in 
consequence of blows on the head. The free communi- 
cation by vessels between this membrane and the brain, 
necessarily occasions an extension of the inflammatory 
action to the substance of the cerebrum. The degree of 
inflammation of the brain varies, in proportion to the af- 
fection of the pia mater. It differs also in the extent of 
the inflamed surface, and in the depth to Avhich it pro- 
ceeds ; these circumstances occasion a difference in the 
degree to which the functions are interrupted. 

Sometimes the inflammation of the brain is attended 
with a copious secretion of fluid, and at others a small 
quantity only is poured out, of course a difference in the 
subsequent symptoms of compression from this cause will 
ensue. 

Mr. Abernethy remarks " If the inflammation be vio- 
lent and general, the patient will be irrational and dis- 
turbed, having his mind strongly affected by wrong ideas 
and endeavouring to act in consequence of them. If the 
inflammation be moderate and affect the surface only, he 
will be irrational, uneasy, restless, and perhaps endea- 
vour to get out of bed, but without the violence of mania. 
Should a moderate inflammation be blended with the ef- 
fects of concussion, he will have less appearance of irra- 
tionality, will lie pretty quiet, and inattentive to slight 
impressions." Some variety will occur probably in the 
symptoms in different patients, *< but in all there will be 
more or less derangement of the powers both mental aiwl 



ELEMENTS OF SURGERY. 3Q3 

corporeal depending upon the degree of inflammation, &c. 
"The symptoms which chiefly characterize the complaint, 
are those of an increase of sensibility ; the pupils of the 
eyes are contracted ; the patient often withdraws his arm 
on being touched, and his pulse and tongue denote ge- 
neral, as well as local inflammation. It seems of the ut- 
most importance that those means which in general cure 
inflammation should be prosecuted very vigorously at the 
commencement of this complaint, since otherwise although 
they will check they will not overcome it. Large blood- 
lettings, brisk purging, and extensive counter-irritation by 
blisters, ought to be employed at the very commencement, 
for if omitted, the disease will then become established, 
and the powers of the body will soon be too much sunk 
to admit of the same active treatment at a later period.'' 

Suppuration takes place when the remedies are un- 
successful in arresting the progress of the inflammation, 
and when this happens the symptoms of compressed brain 
are repeated and a deep coma comes on. 

The pus in this case is very often situated directly 
under the skull, but sometimes under the dura mater, 
and at other times an abscess is found in the brain. The 
trephine can only be used with success when the matter 
can be evacuated, but where the symptoms denote that 
pus has been actually secreted, a perforation through the 
bone at the injured part should be made, and the usual 
means for ascertaining this part, are to be employed. 
Mr. Abernethy's test of scraping the bone, will probably 
be found useful in this instance, as well as in cases where 
the pressure is caused by extravasated blood. When 
the perforation has been made, if the pus exist under the 
skull it will flow out, if under the dura mater this mem- 
brane should be punctured with a sharp lancet, though 
recoveries under such circumstances are not to be ex- 
pected. 



304* ELEMENTS OF SURGERY. 

Although inflammation of the brain generally occurs 
within a few days after the accident which causes it, yet 
in some cases months elapse before its commencement. 
I assisted Dr. Physick to trepan a gentleman, whose 
dura mater we found thickened and in a state of suppu- 
ration, one year after the occurrence of the accident 
which occasioned the formation of the abscess. 

THE OPERATION OF TREPANNING OR TREPHINING. 

The manner of removing portions of the cranium, 
when this becomes necessary is next to be described. 
The various obsolete instruments of the ancients, and 
many of the useless contrivances of modern surgeons 
may be dispensed with in proceeding to this operation, 
for as Mr. Pott remarks, '' Reduction of the number of 
instruments to be used in an operation, and an extreme 
simplicity and plainness in those which may be required^, 
are a part of the merit of modern surgery." The instru- 
ments wanted for removing portions of the skull, are a 
scalpel (with the steel projecting through the handle (Fig. 
1.), a trephine with a sliding centre-pin. (Fig. 2.), a saw 
(commonly called Hey's saw) (Fig. 3.), an elevator (Fig. 
4.) a quill tooth-pick, needles, and ligatures. The lenticular, 
the rhaspatory, the brush, and the other instruments com- 
monly found in the trepanning cases, are quite useless. 

The hair being previously removed, an incision is to 
be made tlirough the scalp down to the bone, and if a 
longitudinal incision should not sufficiently expose the 
surface, it may be crossed by another, and extended in 
any necessary direction. The removal of a portion of 
scalp as practised by the older surgeons and recom- 
mended by Mr. Pott, should never be performed. In 
making the incision down to the bone, great caution is 
in some cases necessary to avoid plunging the knife 



PLATE rr^ 



I-UJ.2 . 





ELEMENTS OF SURGERY. 3q>j 

througli the fracture into the brain. After having denud- 
ed the bone of its pericranium, by means of the end of 
the knife handle, the centre-pin of the trephine is to be 
protruded, and fixed on the part of the skull which is to 
be removed. If in a case of fracture, this centre-pin 
must always be placed upon a piece of firm solid bone, 
not detached from the skull, and as near as possible to 
the fracture, and therefore more than half the bone in- 
cluded by the crown of the instrument will generally be 
uninjured bone. The instrument is to be now freely 
turned backwards and forwards, by the surgeon, who 
presses it firmly against the skull, until a groove is 
formed of sufficient depth to allow the retraction of the 
centre-pin, which must always be carefully withdrawn 
as soon as this groove is made, to prevent a wound of 
the dura mater. The action of the circular saw is to be 
continued and the depth of the groove very frequently 
examined. The teeth of the instrument are to be wiped 
from time to time with a towel, and when they have 
penetrated to the diploe, less resistance is experienced, 
and now a great degree of care is necessary on account 
of the inequalities in the thickness of the inner tabje of 
the skull, in consequence of which one part may be com- 
pletely cut through before the other is nearly divided. 
The tooth- pick is the most convenient probe for ascer- 
taining the depth of the groove, but when the trephine 
reaches the tabula vitrea and has made some little im- 
pression upon it, it is safer to attempt to break out the 
circular portion of bone by means of the elevator, than to 
proceed completely through it with the saw. If any 
part of the bone is entirely divided and the tooth-pick is 
found to touch the dura mater, considerable force should 
be exerted to separate the section of bone without fur- 
ther sawing, as the dangers of a wounded dura mater, 
are very great ; if this, however, be impracticable, the 
VOL.1.' 40 



306 ELEMENTS OF SURGERY. 

action of the trephine should be directed against the 
undivided portion of bone exclusively until it is thin 
enough to be broken oft'; this can always be done with 
the common trephine without resorting to the old instru- 
ment with a file-like circumference. 

If any inequalities of bone remain round the edge of 
the foramen, they may be broken off by the end of the 
elevator ; the lenticular which has been constructed for 
this purpose, is by no means a convenient instrument. 

When one perforation has been made, in general the 
depressed bone may be elevated to the proper level, and 
any loosened portions may be entirely removed. If the 
operation have been performed in order to evacuate ex- 
^ travasated blood or pus, one opening is generally suffi- 
cient^ but if necessary the operation may be repeated. 
The ancient surgeons were in the habit of applying the 
trepan very frequently, and in some cases very numerous 
perforations have been made without fatal consequences. 
In one instance, we are assured that twenty- seven per- 
forations were made through the skull of a nobleman in 
consequence of a fracture, but no one can doubt that the 
removal of portions of the skull is a very serious evil, 
and that it should be performed as rarely as possible. 

The introduction of the straight saw into practice has 
diminished the frequency of using the trephine, and 
although the instrument is to be found in many old 
books of surgery, yet until Mr. Hey of Leeds in a pub- 
lication a few years ago, recommended its use in frac- 
tures of the skull, surgeons were ignorant of its great 
advantages. A variety of cases occur in which it may 
be substituted for the trephine in removing portions of 
skull, without the additional loss of bone which the lat- 
ter instrument occasions. 

With respect to the parts of the skull where the tre- 
phine may properly be applied, I believe the surgeon 



ELEMEXTS OF SURGERY. c^Qy 

liesitates at none, to which he can get access, provided 
the urgency of the symptoms demand the operation. 
The sutures offer no barrier and the large blood-vessels 
none—indeed the basis of the skull is the only part 
where the operation cannot be performed, and with safe- 
ty^ by a prudent operator. Should the longitudinal 
sinus or the great arteries of the dura mater be opened 
eitlifir by a fragment of bone, or by the operator, the 
bleeding is easily arrested by a dossil of lint. I have 
seen a profuse hemorrliagy from a large opening in the 
longitudinal sinus occasioned by a fragment of bone, 
immediately stopped by applying lint over the orifice. 
The middle artery of the dura mater wounded in the 
same manner, is as readily secured. Dr. F. Dorsey of 
Maryland, once tied up this vessel with a needle and 
ligature, and no ill consequences resulted. In some 
cases which I have seen this would easily be effected, 
because the artery could be separated to some distance 
from the dura mater, with which it is not always inti- 
mately connected. I have seen it projecting a quarter of 
an inch from that membrane in an extensive fracture of 
the parietal bone, but if the ligature must pass through 
the dura mater in order to secure it, the operation of 
tying it up ought never to be performed. If the bleeding 
from the vessels of the scalp should not spontaneously 
cease, the needle and ligature are most convenient for 
securing them. 

The only dressing in general required after trephining, 
is a light poultice of bread and milk ; great care should 
be taken to guard against pressure upon the exposed 
brain. The remedies proper to prevent and relieve in- 
flammation are always to be employed with great activity. 
In some cases it may be proper after removing the bone, 
to place the scalp and dura mater in contact and to allow 
tliem to unite, but in a majority of cases this cannot 



gQg ELEMENTS OF SURGERY. 

be effected, and when it is attempted great care should 
be taken to prevent collections of blood and serum or 
pus from being confined under the scalp, and thus com- 
pressing* the brain. Where a small wound of the dura 
mater exists, I believe its adhesion to the scalp at the 
wound and around it, would greatly diminish the dan- 
ger of suppuration in the brain. 

HERNIA CEREBRI. 

When ulceration takes place in the dura mater a tu- 
mour generally rises through it, which has been called 
HERNIA CEREBRI, this tumour in all the cases I have 
seen, consisted evidently of the substance of the brain, 
and under the pia mater in several places clots of blood 
of a dark colour were observed. 

These tumours sometimes acquire a large size, and 
if removed, speedily return. Mr. Abernethy has de- 
scribed some cases which have led him to an opinion 
that " the disease frequently described by the term her- 
nia cerebri, consists of a tumour formed by coagulated 
blood ; f(»r an organized fungus could hardly be produc- 
ed in so short a time as that in which these tumours are 
usually formed." I have no doubt that the tumour con- 
sists partly of coagulated blood, but chiefly of the sub- 
stance of the brain, which is pressed out at the aperture 
through the dura mater, in consequence of an abscess 
having formed in the brain, or immediately under the 
skull, and in consequence of the increased volume of the 
brain which is greatly swelled by inflammation. 

Mr. Abernethy is of opinion that extravasated blood 
pushes out the brain, and that what would be apoplexy, 
if the cranium were entire, becomes fungus cerebri, in 
consequence of the deficiency of bone which allows the 
brain and coagulated blood to protrude. This no doubt 



ELEMENTS OF SURGEnY, gQQ 

occasionally happens, but a considerable quantity of pus 
was found in two cases which I have dissected, and the 
protrusion appeared to be caused by the pressure of this 
pus. Mr. Charles Bell supposes that though Mr, Aber- 
nethy's account be correct, yet two other kinds of tumour 
arise from the brain — the one a fungus excrescence from 
the dura mater, the other a proper organized fungus 
of the brain. 

How far these opinions are correct, I shall not decide, 
but I shall take a greater liberty with his practice than 
with his opinions, and condemn without hesitation his 
proposal to cut off the tumour : this I conceive could not 
answer any good purpose, and would probably be pro- 
ductive of very copious hemorrhagy, which in the ex- 
hausted state of the patient might prove fatal. The best 
application is a light soft poultice, or a pledgit spread 
with simple cerate. Should the tumour however acquire 
a very great size, portions may be separated with the 
knife, as in some of Mr. HilFs cases. Some rare in- 
stances are recorded of recoveries from this dangerous 
affection, but in general it terminates speedily in death. 

Since writing the preceding sentences, I have witness- 
ed in my own practice, the recovery of a patient in 
whom hernia cerebri occurred. On the 5th of August, 
ISl-i, I trepanned a girl, aged between eight and 
nine years, and removed a large portion of the left pa- 
rietal bone. She had sustained an extensive fracture 
and depression of the skull, from falling through a hatch- 
way or trap door in a sugar refinery. She was relieved 
by the operation, from stupor, convulsions, and the usual 
symptoms of compressed brain, and- continued till the 
twelfth day free from all bad symptoms : at this period 
a tumour was perceived protruding tlirough a small ul- 
ceration in the dura mater : it gradually enlarged and 
pulsated strongly. This tumour was unattended by any 



310 ELEMENTS OP SUKGEKY. 

augmentation of fever or stupor, and slowly increased till 
the thirty-first day. My next visit was a few days after 
this, and during my absence (the precise time I could not 
learn) vomiting occurred, during which a copious flow of 
blood took place from some ruptured vessels in the tu- 
mour. From this time I had the pleasure to find the tumour 
gradually subsiding; granulations formed, the tumour 
cicatrized, and afterwards diminished, till it returned to 
the original level of the skull. The patient has remain- 
ed quite well for several years, and bone has now form- 
ed so as nearly to supply the deficiency occasioned by 
the original injury. 

Dr. Physick, in his lectures, suggests the propriety of 
puncturing the tumour with a lancet, in order, if an ab- 
scess can be found, to evacuate tlie pus. 

I have endeavoured to avoid confusing the preceding 
condensed history of the affections of the brain from ex- 
ternal violence by a detail of opinions, or a quotation of 
w^onderful cases. I may now, however, not improperly 
remark that although the opinions of our predecessors on 
the subject, are many of them fanciful and unimportant, 
yet their histories of cases, merit the greatest attention. 
One general principle I would inculcate from them, 
which is, that injuries of the head apparently trifling 
should never be neglected ; and on the other hand, those 
which appear most dangerous and alarming should never 
he despaired of. In proof of this I could select instances 
of death from a blow which scarcely excited attention, 
and of recovery where the brain had been shot through 
by a musket-ball. I have myself seen several skulls in 
an European collection, in which the bony cicatrices de- 
monstrate that large portions of brain and skull had been 
cut out, and subsequent cures had been effected. 

I shall now proceed to relate a case, which I think 



ELEMENTS OF SURGERY-. g»4 

illustrates more of the usual circumstances of injury of 
the brain than any other I have met with. 



CASE. 



P.Welch, aged about twenty-four years, received at 
midnight, June fifteenth, a violent blow from a brick-bat. 
He instantly fell, and was conveyed home stunned and 
scarcely breathing ; a quack in the neighbourhood was 
sent for and by the time of his arrival the symptoms of 
the first stage of concussion had subsided, and the pa- 
tient's breathing was much improved, his pulse rose, he 
remained stupid, but moved occasionally, and when his 
head was touched appeared to suffer pain and put up his 
hands, as patients generally do in the second stage of 
concussion. He remained in this situation till the after- 
noon of the succeeding day, the doctor having declared 
that the skull was not fractured and that he would soon 
be well. His friends becoming uneasy at the continu- 
ance of the stupor had him bled, and sent for surgical 
aid. I made my visit about twenty hours after the acci- 
dent, and foiind him snoring, but if spoken to in a loud 
tone of voice, he attempted to answer, but could not arti- 
culate distinctly. His pulse was full and slow. Over 
the left ear was a contusion and a small wound which 
when touched occasioned pain, and the patient moved his 
head and hands to escape from the examination of it. 
I made an incision down to the bone and discovered that 
a portion of the squamous plate of the temporal bone was 
fractured and depressed. During this operation it was 
with extreme difficulty that the patient could be kept in 
bed ; he screamed, and moved about violently. Under 
these circumstances I postponed operating and drew 
from the arm eighteen ounces of blood in addition to 
several ounces which had flowed from the branches of 
the temporal artery. 



3£3 ELE>fENTS OF SURGERY. 

The next morning, (June seventeenth) no favourable 
change having taken place but on the contrary the stupor 
being increased, I proceeded to remove the depressed 
bone to which the trephine was applied twice, and all 
the depressed bone as large as a half dollar taken 
away, a crack extended forwards toward the parietal 
bone the extent of which appeared considerable, but no 
cause for tracing it further existed. A little extravasated 
blood was found under the skull. After the operation 
the pulse rose and in the evening gxvi of blood were 
drawn from his arm after which he appeared moro 
sensible. 

On the eighteenth, the day after that on which the 
operation had been performed he was evidently better, 
was perfectly rational though still somewhat drowsy, 
had no recollection of the accident — was bled gxii in 
the morning and gviii in the evening, drank toast and 
water. 

For several days no particular alteration was observed, 
the wound appeared sloughy, and a portion of the tem- 
poral muscle which had been cut through sloughed off. 
He vomited occasionally and was bled pretty regularly 
twice a day till the twenty-third. A tumour covered by 
the dura mater gradually protruded at the wound ; this 
membrane was tense and appeared evidently to contain 
a fluid. His stupor was increased. 

On the twenty-fifth, ten days after the accident, the 
nurse informed me he was greatly better and was more 
rational. I immediately suspected that the dura mater 
had given way and that pus had been evacuated ; upon 
inspecting the head this was found to be the case — a large 
quantity of pus had been discharged during the preced- 
ing night and a hole was observed in the dura mater 
through which it had issued. I anticipated now the 
formation of a hernia cerebri, which accordingly hap- 



ELEMENTS OF SURGERY. 3^3 

pencil : on the twenty-seventh (twelve days after the ac- 
cident) a tumour began to appear protruding through 
the aperture in the dura mater which gradually increased 
to the size of a hen's egg and was evidently covered iu 
some parts by the pia mater, and in others had ruptured 
this membrane and appeared to consist of brain and clot- 
ted blood. During the formation of this tumour, and the 
discharge of matter which attended it, the patient regained 
the entire use of his mental faculties, and appeared to his 
friends to be getting well ; I assured them that these hopes 
were delusive and that he would not survive many days. 
He complained of hunger, and his pulse being languid, he 
was allowed chicken broth, and a few oysters. 

On the first of July he had a violent chill, a slougli 
came away from the dura mater, and the tumour of the 
brain enlarged very considerably ; — On the second, copi- 
ous hemorrhage from the tumour ; — On the third at mid- 
night eighteen days after the accident he expired, much 
blood having been previously discharged from the tumour. 

On dissection, the crack noticed during the operation 
was traced, and 1 found it to extend completely round the 
head, having passed through the temporal bone, a small 
part of the parietal, and separating the os frontis into two 
portions, by a crack situated immediately above the 
frontal sinuses parallel to the superciliary ridges. Where 
the fungous tumour had existed clots of blood only were 
seen, and on removing these a considerable hole was 
found in the brain, occasioned by a loss of its substance, 
the brain to some distance round this vacuity was inter- 
mixed with coagula, and completely disorganized, a layer 
of pus, thick and viscid, intervened every where between 
the dura and pia mater, and at one place under the fis- 
sure in the bone, an extravasation of one half an ounce of 

blood was found. 
In this case the effects of concussion were very evi- 

VOL. I. ^1 



g£4 ELEMENTS OF SURGERY. 

dent, afterwards those of compression^ then the usual ef- 
fects oiinflammation (not so distinctly marked as in some 
cases, because compression still existed) followed by snjp- 
puration and by hernia cerebri. 

In consequence of gun-shot wounds and other contu- 
sions of the skull, exfoliations occasionally happen, some- 
times of one and sometimes of both tables of the skull. 
When the external table is killed, and exfoliation com- 
mences, the inner table inflames, and the action of the ab- 
sorbents as described formerly, removes the earthy mat- 
ter of the bone, granulations shoot out from the inner table 
and push off the scale of dead bone, after which, these 
granulations probably secrete and deposit osseous matter 
and are converted into solid bone. This process goes on 
more rapidly in young than in old subjects. In some cases 
it is performed very slowly in consequence of the granu- 
lations shooting up into cavities in the dead bone, and thus 
connected they prevent for some time the separation ; 
where the delay is evidently owing to this cause some 
force may be used in removing the dead bone. If both ta- 
bles of the skull are killed as in cases of gun-shot wounds, 
the symptoms generally call for the trephine, but if this 
be not applied, the separation of the dead bone is effected 
in the usual manner, and granulations arise from the dura 
mater and fill up the space. The deficiency of bone after 
portions of the skull have been removed, is supplied by 
granulations from the surrounding bone and from the dura 
mater. The bone forms first in contact with the remain- 
ing solid bone, and a thin plate afterwards, extends gra- 
dually over the aperture. Previously to the formation of 
this plate of bone, the brain is defended only by a soft 
cicatrix of skin under which it may be observed pulsating. 
From this exposed state it is proper to defend it, espe- 
cially when large portions of skull are deficient by means 
of firm plates of tin, silver, or leather, which may be 
worn under a wig, or cap, until the bone is replaced. 



ELEMENTS OF SURGERY. gj^g 

CHAPTER LI. 

Diseases of the Eye and its Appendages. 

Having treated of the most usual accidental injuries tg 
which the body is exposed and of the remedies to be em- 
ployed, we pass on to describe certain morbid affections 
submitted to the care of the surgeon. 

The term disease does not convey a precise and accu- 
rate notion of many of these affections ; in a qualified 
sense, however, it may be retained and cannot mislead, 
when the nature of the various cases is understood. 

Inflammation attacks the eye and its appendages as well 
as the other parts of the body ; it may be excited by acci- 
dental irritations, or by diseases of tlie constitution. In 
gome cases it makes its approach without any obvious re- 
mote cause. 

Inflammation of the eye-lids occasions some pain, but 
less than when the eye-ball is affected — the lids swell in 
consequence of an effusion of serum into the cellular tex- 
ture — the skin becomes red and a burning sensation is 
felt. In some instances, this inflammatory tumefaction 
of the eye-lid comes on at night, and as only one eye-lid 
is generally affected the patient ascribes it to the bite of 
an insect 5 the cause is not always easily ascertained. 

If fever accompany it, as is sometimes the case, the pa- 
tient should lose blood from the arm, if not, a brisk mer- 
curial cathartic and low diet will generally remove the 
affection very promptly. A lotion of brandy, or cam- 
phorated spirit is often found useful. Should it resist 
these remedies, repeated blood-letting, the application of 
a dozen leeches, and the usual antiphlogistic measures are 
to be employed. 



316 ELEMENTS OF SURGERY. 

A discharge of pus from the edges of the eye-lids, call- 
ed psoROPHTHALMY ofteu calls for the aid of the surgeon. 
The patient waking in the morning finds his eye-lids 
closed by a secretion of pus which has dried and keeps 
them in contact. The glands of Meibomius are generally 
considered as the seat of this affection. Dr. Physick 
has been led to believe from his own observations, that 
the inflammation is seated at the roots of the eye-lashes. 
The affection of the head called tcenia capitis is probably 
of the same nature, ulceration existing in both cases at the 
roots of the hair. One proof of the correctness of this 
opinion is, that the hair being pulled out the inflammatiou 
often gets well, and another, that the tar ointment and 
spermaceti oil, remedies very successful in toinia capitis, 
are advantageous in the present case. 

The edges of the eye-lids are sometimes ulcerated m 
this complaint. The most successful application is the 
citrin ointment, applied to the part; a solution of lunar 
caustic has also been used with great benefit. Common 
mercurial ointment is sometimes successful. Lamp oil, 
and tar ointment I have several times used with advan- 
tage. When the inflammation is very great, leeches 
should be applied, and purges administered. 

A chronic inflammation of the eye-lids called lippi- 
TUDO sometimes proves extremely obstinate ; the patient's 
eye appears surrounded with a red circle, and the lids are 
agglutinated in the morning. The treatment recommend- 
ed in the last case is sometimes successful in this ; but 
in many cases it is extremely obstinate and requires great 
attention to diet and regimen. I have known instances 
where it has lasted through life, and has appeared in se- 
veral members of the same family. 

The eye-Uds are subject to an inflammatory tumour 
called HORDEOLUM or stye. It resembles at first a small 
4nmple situated on the edge of the eye-lid, which aug- 



ELEMENTS OF SURGERY. ^{7 

ments, becomes painful and suppurates. It is in fact a 
small boil, or phlegmonous tumour, and in general gets 
well without any surgical aid, occasionally an induration 
remains after the inflammatory tumour has subsided. If 
this become troublesome it may be destroyed by lunar 
caustic. 

The eye-lids are subject to two very opposite affections 
which become sources of great trouble and inconvenience, 
the one an eversion of the lid, called Ectropium^ the other 
an inversion called Entropium, or Trichiasis. 

ECTROPIUM. 

The eversion of the eye-lid most frequently occurs in 
the lower lid, which is turned outwards towards the cheek 
and does not come into contact with the eye. Inflamma- 
tion results from the exposure of the eye, and from the 
unnatural situation of the pun eta lachrymalia, the tears 
cannot pass through them and of course overflow the 
cheeks and a very unpleasant tumour of a red, fungous 
appearance forms in consequence of the distension of the 
vessels of the conjunctiva. The complaint is occasioned 
sometimes by the contraction of granulations in the heal- 
ing of burns, wounds, or ulcers, on the cheek, butoftener 
from a relaxation and elongation of the eye-lid. The 
only remedy hitherto relied on, is the removal of the 
everted lining membrane of the eye-lid, which becomes 
indurated and enlarged ; when this is done by a scalpel 
or scissars, the lid should be supported in its natural situ- 
ation by a compress carefully applied, and the wound in 
healiu"- generally contracts suflBciently to counteract the 

disease. 

A more inn-enious operation, however, is described by 
Sir William Adams in a work published in 1812, at 
London for the cure of this affection^ it consists in cutting 



318 ELEAIENTS OF SURGERY. 

out a portion of the lower eye-lid resembling the letter 
Y — ^tlie piece thus removed is one-third of an inch wide 
at its upper part, the sides of the Avound are approxi- 
mated by a stitch, and the diseased conjunctiva cut off— 
this effects invariably a complete and speedy cure. 

ENTROPIUM. 

In the ENTROPIUM or trichiasis, the eye-lid is invert- 
ed upon the eye, in consequence of which, the cilia irri- 
tate excessively the surface of the eye, and keep up a 
constant and violent inflammation. According to Scarpa 
and other writers, two species of this disease are met 
with; in one the cilia are turned inwards without the 
tarsus having changed its natural position and direction, 
in the other the tarsus is inverted, and consequently all 
the eye-lashes are in contact with the globe of the eye. 
The second form is most common, and to this only the 
term Entropium is properly applied. 

The causes of Trichiasis are by no means well under- 
stood — ulceration and consequent cicatrices are supposed 
to have produced it in most cases, but of this there is no 
proof. It seldom occurs in the under eye-lid. 

The consequence of the inversion of the eye-lids is ft 
constant irritation and inflammation of the eye, from 
which the cornea becomes opaque ; but the patients from 
time to time relieve themselves by pulling out the cilia, 
and then the inflammation abates ; it is, however, soon 
repeated when the eye-lashes begin to grow, and blind- 
ness sooner or later results ; nor is this a termination of 
the patient's sufferings, for the inflammation goes on, and 
the pain continues. A callosity and complete change in 
the structure of the eye is the only event which affords a 
complete relief to the unhappy sufferer. 

A great variety of means have been proposed and 



ELEMENTS OP SURGERY. gjg 

adopted for the cure of this disease, which it is unneces- 
sary here to detail. 

In reflecting on the nature of the complaint, several 
years ago, I was induced to think that the eye-lid could 
very readily be cut half off, without much inconvenience, 
because the orbicularis muscle is capable of contracting 
in such a degree as to throw the folds of skin into nu- 
merous wrinkles, thereby demonstrating that much of it 
could be removed, and the eye still be closed. A case of 
trichiasis came under my care in the Philadelphia Alms- 
house, in July 1810, in which several operations had 
been performed, but without effecting a cure : about 
one-third part of the cilia were inverted. In this case I 
made an incision through the tarsus, and cut out com- 
pletely all that portion of the eye-lid, from which the 
eilia proceeded. My patient in a few days was perfectly 
cured, was extremely pleased with the operation, and 
very little disfigured ; indeed, compared with her in- 
flamed eye, her appearance was improved. Encouraged 
by the success of this case, I have twice since perform- 
ed the operation of removing totally the lower half of the 
tarsus cartilage, together with the skin covering it and the 
inverted cilia; the success has been complete in both 
cases — the wound healed up very readily, the inflamma- 
tion quickly subsided, and the opacity of the cornea was 
soon removed. 

By one of those coincidences which are often occur- 
ring, the late Mr. Saunders, of London, contrived and 
performed the same operation, and with equal success. 
A small volume on the diseases of the eyes, which for 
the first time I saw during the present winter, though it 
was published in 1811, contains an account of this ope- 
ration. Mr. Saunders remarks, " the certainty of its re- 
lievin°- the patient, is what I more value than the credit, 
if there be any, of having suggested it f and in this 



320 ELEMENTS OF SURGERY 

sentiment I heartily join him. I shall therefore proceed 
to describe the manner of operating proposed by Mr. 
Saunders, and afterwards relate my own method. 

Mr. Saunders directs the operation to be performed 
as follows : " a piece of thin horn or a plate of silver 
having a curvature corresponding with that of the eye- 
lid, is to be introduced, and its concavity turned towards 
the globe within the eye-lid which is to be stretched 
upon it. An incision is to be made through the integu- 
ments, and orbicularis palpebrarum, immediately be- 
hind the roots of the cilia to the tarsus, and should ex- 
tend from the punctum lachrymale to the external an- 
gle. The exterior surface of the tarsus is then to be 
dissected until the orbital margin is exposed, when the 
conjunctiva is to be cut through directly by the side of 
the tarsus which must now be disengaged at each extre- 
mity ; the only caution necessary being to leave the 
punctum lachrymale uninjured." 

The manner in which I have performed the operation 
is extremely simple. A hook is passed through the edge 
of the eye-lid in order to gain a secure hold of it, and 
with a pair of sharp scissors the necessary portion of the 
eye-lid is removed by two or three cuts. " Nothing can 
be more simple than this piece of dissection." A remark 
applied by Mr. Saunders to his operation, but which is 
much more applicable to mine. The punctum lachry- 
male must be carefully avoided. 

The wound generally heals in a few days ; no dres- 
sings are necessary, but a soft compress may be lightly 
bound over the eye. Mr. Saunders says a fungus ai'ose 
from the cicatrix in all his cases, which required caus- 
tic or the knife ; all the cases I have seen, healed imme- 
diately without any inconvenience, and the deformity is 
not so great as would be imagined.* The appearance 

* The operation is I believe new, thougli Hallerin liis Bibliotheca Chirurgica 
states, that Rhazes recommended cutting and burning tlie eye-lid, in similar 



ELEMENTS OF SURGERY. 22i 

ef the eye after the cure, is represented in Fig. 2. of the 
Plate next succeeding.* 

When the eye-lids are contracted by cicatrices so as 
no longer to cover the eye, systematic writers have call- 
ed tiie affection lagophthalmy, or hare-eye. I have 
seen it in consequence of burns and there is no remedy 
but careful dissection of the surrounding parts, by which 
the skin may be loosened in suflRcient quantity to defend 
and cover the eye; after the dissection care must be 
taken to prevent by adhesive plaster or even a suture if 
requisite, the subsequent retraction of the skin. 

cases ; the nature of his operation I cannot ascertain, as the only copy of Rhazes 
which I have been able to see, contains nothiiig- on the subject. It is a black 
letter edition, very ancient in barbarous JLatin, belonging to the Loganian 
library in this city. 

• Since my first edition an enlarged experience has convinced me «f the 
propriety of this operation. 



VOL. I. 43 



322 ELEMENTS OF SURGERY. 

CHAPTER LII. 

Of Ophthalmia. 

Inflammation of the eye^ or in medical language oph- 
thalmia, is a frequent, and very distressing complaint. 
Its symptoms are very well known ; they generally com- 
mence with a severe pain in the eye, redness of the eye- 
ball, and a copious secretion of tears — the patient is un- 
able to bear the light, and keeps his eyes closed — some- 
times a violent burning is perceived in the eye ; head- 
ache and in general fever attend — the inflammation is 
either seated in the adnata, or in the globe of the eye, in 
which latter case there is less external evidence of in- 
flammation, but the same general symptoms. In some 
cases an effusion of blood takes place into the cellular tex- 
ture under the adnata, and occasions a great tumefaction. 

Coagulating lymph is sometimes poured out by the in- 
flamed vessels, and opacity of the cornea is the conse- 
quence. In some cases a pimple or inflamed speck ap- 
pears in some part of the adnata, generally in the vici- 
nity of the cornea. Small red vessels are often seen ra- 
mifying over the cornea. 

It is unnecessary to enumerate the various causes of 
ophthalmia ; they are numerous mechanical and chemical 
irritants, and certain diseases, as small-pox, syphilis, 
scrofula, catarrh, &c. 

When the disease occurs in the adnata only, the pain 
is tolerable, compared with the sufferings of those patients 
in whom the internal parts of the eye are affected with 
severe inflammation ; in these the pain is excruciating, 
and if it be not soon relieved, blindness is generally the 
result, and death sometimes takes place. 

The treatment of ophthalmia, whether confined to the 



ELEMENTS OF SURGERY. 3^3 

adnata, or seated more internally, consists in the active 
employment of the usual remedies for inflammation. Of 
course the remote causes, if they continue to act, should 
be removed ; all extraneous matters which may irritate 
the eye should be wiped off; this may generally be done 
by passing a small piece of rag wet with clean water upon 
the end of a probe, round the eye between the eye and 
lid, or by injecting a stream of milk and water under the 
eye-lids by means of a syringe. In many cases, how- 
ever, the foreign substance sticks in the cornea or sclero- 
tica, and cannot be thus easily removed. It is very com- 
mon for blacksmiths, in filing iron, to detach small por- 
tions of the metal with great force, so that when they 
strike the eye, they penetrate to some depth. In these 
cases the point of a lancet, or a cataract knife, must be 
used to detach the foreign body. 

The remote causes being removed, blood-letting is to be 
performed, as extensively as the nature of the case may 
require. After this remedy has been carried as far as 
may be necessary, topical bleeding by leeches, and cup- 
ping in the neighbouring parts is to be next used. The 
European surgeons do not employ blood-letting so exten- 
sively in ophthalmia, as is necessary in the treatment of 
the complaint in this country. I have known, in one case, 
seventy bleedings required for the cure of an obstinate 
acute ophthalmia; the quantity of blood lost at each ope- 
ration was generally six or eight ounces. In the Penn- 
sylvania hospital, I have generally directed the patients 
afflicted with acute ophthalmia to be bled every second 
day, and on the intermediate day to be purged ; to live 
upon a very abstemious diet, and to remain constantly in 
a dark room. These remedies are in almost every re- 
cent case very speedily successful, and active measures 
ouo-ht surely to be preferred to tampering with serious 
diseases. 



3;jJ4; ELEMENTS OF SURGERY. 

In some cases, after bleeding, and cupping, and leeches 
liave been tried, if the inflammation continue, scarifica- 
tions become necessary ; the vessels of the adnata may 
be conveniently divided by the edge of a sharp scalpel, 
or the shoulder of a lancet. A few drops of blood eva- 
cuated in this way, from the inflamed part, will oftea 
prove extremely serviceable. 

Purges are to be frequently administered, the saline 
cathartics are generally employed, and antimonial prepa-' 
rations in combination with nitre are also useful. 

Blisters to the back of the neck, or behind the ear, 
or to the forehead, are in many cases extremely benefi- 
cial; but Dr. Physick has introduced a mode of apply- 
ing blisters, in cases of ophthalmia, which is more quickly 
useful than any other ; the plaster is to be spread with 
the epispastic ointment covered with gauze, and applied 
directly over the eye, the lids being closed ; in this 
manner the whole surface of the upper and lower eye- 
lid, and a portion of the cheek, are blistered, a copious 
discharge of serum takes place, and great relief is in ge- 
neral immediately experienced. I have for several years 
availed myself of this practice, and have been much 
pleased with its efficacy. I was formerly in the habit of 
cutting ojff the cilia, and applying a strip of adhesive 
plaster to prevent the flies from coming in contact with 
the eye, but of this, if the blistering plaster be carefully 
prepared, there is no risk, and I have often omitted the 
precaution ; indeed, the copious secretion of tears would 
wash out any extraneous matter which might be insinuat- 
ed between the eye-lids. 

When, notwithstanding a vigorous perseverance in the 
use of the preceding remedies, the inflammation continues 
unabated, and great pain is felt in the ball of the eye, 
mercury should be administered in such a manner as to 
excite a speedy salivation, the ointment should be rubbed 



ELEMENTS OF SURGERY. gag 

upon the thighs, and calomel administered in doses of 
two or three grains in the twenty-four hours. 

No collyriiim hut of the mildest kind should be em- 
ployed during the acute stage of ophthalmia. Milk and 
water answers very well. Tlie pith of sassafras, infused 
in water forms a mild mucilage, which in these cases is a 
very pleasant application to the patient ; the young twigs 
of the sassafras split open, afford considerable quantities 
of pith ; a teaspoonful will render eight ounces of wa- 
ter sufficiently viscid. A soft light poultice of bread and 
milk sometimes relieves the pain of ophthalmia, but in 
general compresses of soft linen, wet with cold water or 
milk and water often changed, give more ease ; the poul- 
tice keeps the part too hot, and its weight is an inconve- 
nience. 

After the more active symptoms of inflammation have 
abated, the employment of gently irritating or astringent 
coUyria, becomes useful ; the formula I have found most 
beneficial is the following : 



&> 



R. Sacchar : saturn : (Acetatis plumbi) 

Vitriol: alb: (Sulphatis zinci) gi'- iij. 

Laud : liquid : 3. ij. 

Aq : fluvial : 5. iv. 

M. f. coUyr. 

The addition of sij of vinegar sometimes improves the 
medicine. Dr. Physick employed tar water several 
years ago in a most obstinate case of ophthalmia, which 
had resisted all the usual remedies, it proved completely 
and speedily successful. 

In the employment of an eye-water, a rag wet with 
the fluid should be placed over the eye- lids, and occa- 
sionally they should be opened so as to admit it into 
contact with the ball of tlie eye. The tar water should in 



326 ELEMENTS OF SURGERY. 

the first instance be diluted, and afterwards applied of 
the usual strength. Diluted laudanum, and the vinous 
tincture of opium, are in some cases very useful as colly, 
ria. A great variety of collyria have been contrived ; 
I have already named those which appear to me most 
useful. 

In general by these measures the inflammation is re- 
lieved ; but it sometimes terminates in suppuration, and 
pus is poured out under the cornea, forming the disease 
called HYPOPiox. In these cases it is proper to make a 
puncture with a cataract knife through the cornea for the 
evacuation of the pus ; for if this be suifered to remain 
until ulceration takes place, vision will inevitably be de- 
stroyed. It generally happens, however, that brisk purg- 
ing, and a continuance of the antiphlogistic measures, 
produce an absorption of the effused pus, and render it 
unnecessary to puncture the cornea. 

Confinement to a dark room, and a very abstemious ve- 
getable diet, should be enjoined during the whole course 
of the disease. Setons and issues in chronic cases are 
sometimes useful ; they may be made on the back of the 
neck. When the inflammation abates, light should gra- 
dually be admitted to the eye, and a very cautious return 
made to the usual habits of diet and exercise. 

Within a few years much attention has been excited in 
England by an epidemic ophthalmia, evidently conta- 
gious, accompanied by a puriform discharge from the ad- 
nata. To this complaint the British surgeons have af- 
fixed the name of Egyptian ophthalmy, from its resem- 
blance to the disease which occurred among the troops in 
Egypt, in the year 1801. 

This malady commences with a sensation of irri'^tion, 
as if from a mote ; the white of the eye becomes sudden- 
ly red, and the lower eye-lid very vascular. In this stage 
it readily yields to active antiphlogistic remedies. If 



ELEMENTS OF SURGERY. 3giy 

these be not employed, the disease advances ; and in the 
second stage the upper lids inflame, and secrete a ^^ scald- 
ing fluid,'' which excoriates tlie cheeks, and suppuration 
soon follows. The remedies for inflammation are still 
proper, and sometimes successful ; but if they are not, the 
third stage comes on, the cornea inflames, becomes opaque, 
and ulcerates. 

Numerous treatises on this subject have appeared in 
the medical writings of Great Britain. An excellent his- 
tory of it may be seen in Mr. MacGrregor's paper, de- 
scribing the disease as it occurred in the military asylum 
at Chelsea, in the 3d vol. Medico-Chirurgical Transac- 
tions. Sir William Adams has been very successful in 
the treatment of the Egyptian ophthalmia. His practice 
has been approved by the most respectable surgeons of 
London, and consists in copious depletion in the early 
stage; and in the latter, cutting oflP with a knife the gra- 
nulations which arise from the adnata, and irritate the 
cornea. For a minute account of this and other diseases 
of the eye, the reader is referred to his excellent treatises 
written in 1812 and I8I7. 

In cases which I presume to call Egyptian ophthal- 
mia, I have cut off the granulations of the adnata with 
obvious advantage. 



3^ ELEMENTS OF SURGERY. 

CHAPTER LIII. 

Unguis or Pterygium. 

Unguis or Pterygium, is an aflfiection of the eye, not 
uiifrequently met with ; it consists in an enlargement of 
the vessels of the adnata proceeding from the inner can- 
thus of the eye, and at length forming a dense opaque 
red membrane of a triangular figure pointing and pro- 
gressing towards the cornea, over which at length, it 
gradually spreads and of course impedes vision, in pro- 
portion to its extent. In some rare cases it proceeds 
from the external canthus of the eye. Scarpa observes 
that the unguis in some rare instances proceeds from 
otiier parts of the globe of the eye, but always maintains 
a triangular shape, — the apex of which is presented 
towards the cornea ; occasionally two or three pterygia 
form upon the same eye; when these unite upon the 
cornea, a complete obstruction to vision takes place. 

Scarpa considers the vessels of the eye in chronic 
ophthalmia to be in a varicose state, and in the present 
case in addition to the varicose state of the vessels which 
are extended over a certain part of the cornea, there is 
a preternatural thickening of the thin lamina of the con- 
junctiva which covers it, upon which these small vari- 
cose veins are situated. 

Hence it seems that the pterygium appears at first, to 
be a new membrane formed upon the cornea, while it is 
nothing more than the fine lamina of the conjunctiva, 
forming its natural external covering, which in conse- 
quence of chronic ophthalmia has degenerated from a 
transparent into a thick and opaque tunic interwoven with 
varicose vessels. 



ELEMENTS OF SURGERY. ggn 

Scarpa supposes the unguis to be nothing more than 
an increase of the same aflPection which forms nebulae, 
or spots on the cornea. These nebulsB consist of dilated 
kuotty vessels upon the cornea, which ought in their 
forming state to be treated by astringent collyria, and sti. 
mulating applications, as the citrin ointment, &c. in order 
to prevent their extending over the lucid cornea and thus 
impeding vision. A peculiarity of unguis or pterygium 
is that it appears very loosely connected with the sclero- 
tica; if taken hold of by a hook or forceps it moves ea- 
sily, and seems connected only by loose cellular texture. 
>Scarpa remarks that cancer has sometimes resulted from 
this complaint. 

The remedy consists in seizing the thickened mem- 
brane with a hook or pair of forceps and dissecting it 
carefully off with a pair of curved scissors, (Fig. 3.) 
Where it adheres to the cornea the union is more intimate, 
and here a sharp knife is the most proper instrument 
for the dissection. It is most convenient to commence 
the incision near the canthus and proceed towards the 
cornea. 

Scarpa remarks that in some cases after the removal 
of the pterygium, the cicatrix prevents the freedom of 
motion outwards, to avoid which inconvenience in the 
treatment of pterygia w hich have a very extensive base 
upon the white of the eye, he has found it convenient to 
divide them from the apex, only as far as the cornea 
and sclerotica unite, and then to separate them at their 
base by a semicircular incision including about a line 
in breadth of the substance of the conjunctiva, in a di- 
rection concentric to the margin of the cornea. Ey ope- 
rating in this manner, he has found that the after-treat- 
ment is much shorter, than when it is executed after the 
common method, that the cicatrix does not form a ridge 
or frjenum, and that the conjunctiva being stretched cir- 

voi.. t: 43 



ggQ ELEMENTS OF SURGERY. 

cularly and equably upon the white of the eye by the ci- 
catrix, loses that relaxation and varicose state of its ves- 
sels which formed the base of the pterygium. This 
nicety however, is not necessary where the pterygium is 
small, and does not extend much upon the white of 
the eye. 

After the operation no particular dressings are requi- 
site, a wet compress should be loosely bound upon the 
eye and the patient for a few days confined to a low diet. 

A species of disease very analogous to this is called 
Encanthis ; it is a tumour of the same texture as the 
unguis and formed in the same manner, growing from 
the caruncula lachrymalis and semilunar fold of the ad- 
nata. It is to be extirpated by sharp scissors. 



ELEMENTS OF SURGERY. 33 j^ 

CHAPTER LIV. 

Opacity of the Cornea and Artificial Pupil. 

Inflammation of the eye sometimes terminates in opa- 
city of the cornea. Several distinct appellations have 
been given to the various forms of opacity in the cornea, 
as nebula, albugo, leucoma, &c. ; for an account of these 
I refer to Scarpa. 

In some cases the texture of the whole cornea appears 
to be changed, in others opaque spots are visible ; some- 
times tlie opacity depends on increased vascularity and 
subsides when the inflammation is over, in others it re- 
mains permanent. 

Some practitioners are in the habit of blowing into the 
eye powdered sugar, molasses, white vitriol, or pulve- 
rized glass, with a view to grind off this film, as they call 
it ; the practice is extremely pernicious, and ought never 
to be used ; the remedies for inflammation already recited 
are the only ones in which confidence should be placed. 
When a portion of the cornea remains lucid, an artificial 
pupil if necessary, may be made opposite to this lucid 
spot in the cornea, and thus vision will be restored ; the 
operation should not be performed unless the patient has 
lost the sight of both eyes. The same operation may also 
become necessary, in cases where the pupil has become 
obliterated, from an adhesion of the iris at its margin, in 
consequence of inflammation. In both these cases Dr. 
Physick has for many years been in the habit of making 
a section of the cornea, as for the extraction of cateract, 
and afterwards of removing a portion of the iris, by means 
of a pair of forceps terminating in narrow extremities upon 
one of which is fixed a sharp circular punch (Fig. IS.) 



332 ELExMENTS OF SUllGERY. 

the iris in cases where the pupil is ohliterated, must be 
punctured by the point of the knife in making the section 
of the cornea, and then the forceps can readily seize it. 
A variety of methods have been contrived for effecting this 

purpose. 

Baron WenzePs I think is preferable to all be^vre de- 
scribed. The one I have just noticed is an improvement 
of Baron WenzePs. 

Mr. Charles Bell remarks that he had thought it pos- 
sible to restore sight by making an artificial pupil, in 
cases of opaque cornea ; what he considered possible, I 
have seen accomplished in a variety of cases. Indeed 
the advantages of the operation would be limited to a very 
narrow boundary if it were only adapted to cases in 
which the pupil is obliterated, because this is a very rare 
case in comparison with opacities of the cornea. 

A portion of iris ought in most instances to be remov- 
ed, because a simple puncture or incision through it is 
apt to contract, and of course it becomes necessary to re- 
peat the operation. 

Professor Scarpa has lately contrived a mode of form- 
ing artificial pupil which consists, not in making an aper- 
ture through the iris, but in separating the iris from the 
ciliary ligament. The patient being seated, and held as 
in the operation for cataract, a couching needle is to be in- 
troduced through the sclerotic coat, about two lines dis- 
tant from the cornea ; the needle enters on the side next 
to the external canthus, and its point is made to advance 
as far as the upper and internal part of the margin of the 
iris, that is, on the side next the nose. The instrument 
is then made to pierce the upper part of the internal mar- 
gin of the iris close to the ciliary ligament, until its point 
is just perceptible in the anterior chamber of the aqueous 
humour. As soon as the point of the needle can be seen 
in the anterior chamber of the aqueous humour, it should 



ELEMENTS OF SURGERY. ggo 

be pressed upon the iris from above downwards, and from 
the internal towards the external angle ; by this means a 
separation will be made of the iris at its margin, from the 
ciliary ligament and a black spot will be observed. The 
light can in this manner be transmitted to the retina. 

I have mentioned the operation, because sometimes the 
only lucid part of the cornea is its margin, and in such 
cases, Scarpa's operation would probably answer ex- 
tremely well, but under common circumstances Dr. Pliy- 
sick's is vastly preferable, because the pupil can be made 
wherever it is requisite, and with as little pain and dif- 
ficulty as possible.* 

Mr. Saunders has recommended the use of Belladon- 
na to prevent the obliteration of the pupil, when the iris 
is inflamed : it produces a great dilatation of the pupil. 
Stramonium has been employed in this country with the 
view of dilating the pupil in certain cases, and would pro- 
bably be equally effectual in this ; indeed most of the nar- 
cotic plants possess the same property. 

ULCERS OF THE CORNEA. 

These sometimes form in consequence of inflamma- 
tion, and sometimes an accidental injury ends in ulcera- 
tion. The application of lunar caustic is the proper re- 
medy. It is to be scraped to a point ; secured in a quill, 
and then applied to the ulcer, and suddenly removed; 
the slough separates in a day or two, and the operation 
is to be repeated ; the pain and intolerance of light gra- 
dually diminish, and the ulcer generally fills up and ci- 
catrizes. For more minute information on ulcers of the 
cornea, I refer to Wardrop's morbid Anatomy of the Hu- 
man Eye. 

* It mav not be improper in this place to ascribe the invention of the artifi- 
cial pupil to Clieselden, his publication on the subject is contained in the Phil. 
Trans, for 1735. His mode of operating' has lately been revived and modified 
by Sir Wni. Adams. Sec his works. 



334i ELEMENTS OF SURGERY. 

CHAPTER LV. 

Fistula Lachrymalis. 

The tears secreted by the lachrymal gland after lubri- 
cating the eye, are taken up by the puucta lachrymalia, 
and conveyed to the lachrymal sac, whence they pass 
through the ductus ad nasum into the nose. This ductus 
ad nasum, however, is liable like all other canals in the 
body to stricture. Whenever in consequence of a stric- 
ture in this duct, the course of the tears into the nose is 
interrupted, they accumulate in the sac which becomes tu- 
mid, and upon being pressed they regurgitate and flow 
partly over the cheek, and partly through the nasal duct. 
The tumour is situated on one side of the root of the nose 
below the inner canthus of the eye. The tears are con- 
stantly ovei-ilo wing the eye, because the sac being full the 
puncta can receive no more. To the disease in this state 
the term fistula is improperly applied. The patient ex- 
periences but little inconvenience from it, except a con- 
stant watery eye ; no pain and inflammation exist. Even- 
tually, however, the stricture becomes complete, the sac 
inflames and suppurates, and now a fistulous sore is form- 
ed which discharges tears mixed with mucus and pus. It 
is generally accompanied with inflammation of the eye, 
and often with caries of the os unguis. The puncta, in 
this stage are often obstructed, and no tears find their 
way into the sac, but all which are secreted pass over the 
eye-lids. 

In the first stage of the disease which has been called 
EPIPHORA, and by Scarpa the puriform discharge of 
THE eye-lids, while the lachrymal sac is entire, the 



ELEMENTS OF SURGERY. gg^ 

only remedy necessary is to inject by means of a fine sy- 
ringe, called from its inventor Anel's, a stream of wann 
water through the puncta lachrymalia which will wash 
away any thickened mucus or similar obstruction. The 
sac should be kept empty by frequent pressure. Scarpa 
recommends in addition to this washing out of the " via 
lachrymalia" the use of an astringent ointment, to be ap- 
plied between the eye-lids and upon the ball of the eye. 
He prefers the celebrated ophthalmic ointment of Janin. 
It is composed of the following ingredients ; hogs-lard 
half an ounce, prepared tutty and armenian bole of each 
two drams, white precipitate (calx hydrargyri alba) a 
dram. Scarpa dilutes the ointment at its first application 
by adding hogs-lard. By the use of these remedies the 
disease has in many cases been prevented from ulcerating 
and has been completely cured. 

Mr. Pott who condemns the use of Mr. AnePs probes 
which were intended to pass through the lachrymal 
puncta into the nose, recommends the employment of the 
syringe; he found it, however, sometimes unsuccessful. 
Mr. Ware's testimony is in favour of the syringe of Anel ; 
he injects warm water through the lower punctum and 
places a finger upon the upper one to prevent its escape. 
He repeats the operation four or five days in succession. 
If he is unsuccessful in forcing any of the fluid into the 
nose, he makes use of topical blood-letting, from the an- 
gular vein, or by a leech applied near the lachrymal sac. 
He also varies the injection, and tries the effect of a weak 
vitriolic or anodyne lotion. Mr. Ware has in some cases 
passed a fine gold probe through the punctum, when un- 
able to force the fluid into the nose, and by gently in- 
sinuating this, he has overcome the obstruction, and im- 
mediately afterwards the injection has readily found its 
way through the ductus ad uasum. 

Mr. Ware remarks that " when an epiphora is occa- 



336 ELEMENTS, OF SURGERY. 

sioned by an acrimonious discharge from the sebaceous 
glands on the edges of the eye-lids, it must be evident, 
that injections into the sac will be very insufficient to 
accomplish a cure, because the sac is not the seat of the 
disorder. The remedies that are employed must be di- 
rected, on the contrary, to the ciliary glands themselves, 
in order to correct the morbid secretion that is made by 
them ; and for this purpose, I do not know any applica- 
tion that is so likely to prove eifectual as the unguentum 
hydrargyri nitrati, of the new London Dispensatory, 
which should be used here in the same manner in which 
it is applied in common cases of the psorophthalmy. It 
will be proper to cleanse the eye-lids every morning, 
from the gum that collects on their edges during the night, 
with some soft unctuous application; and I usually ad- 
vise to apply to them, two or three times in the course of 
a day, a lotion composed of three grains of white vitriol, 
in two ounces of rose or elder-flower water." Mr. Ware 
recommends whenever coUyria are applied, to substitute 
for linen compresses, eye-glasses, or to apply the fluid 
by camel's h.ir pencils. 

In the second stage of tlie disease, where the fistulous 
sore exists, or where the inflamed state of the parts pre- 
cludes the hope of any other termination, a different 
mode of treatment becomes requisite. 

When the abscess of the sac has actually formed, it is 
best to open it with a lancet, because a puncture of this 
kind leaves a smaller scar than the sore formed by the 
absorbents. A probe should now be passed if possible 
into the ductus ad nasum; if it enter readily a bougie 
should be introduced of a conical form, so as to dilate the 
canal at the part where the obstruction exists, and this 
bougie should be suflfered to remain, and a superficial 
mild dressing applied to the sore. In some cases this 
simple plan succeeds effectually. If, however, a bougie 



ELEMENTS OP SURGEllY. ooiy 

cannot readily be passed, a silver style or short probe is 
to be substituted ; the size and form of this instrument is 
represented in Fig. I7. The circular button on its ex- 
tremity may be covered with black sealing wax, or court 
plaster; when this instrument is introduced, the patient 
must wear it for several months, care being taken to 
cleanse it twice or thrice a week, and to inject when- 
ever it is removed, a stream of tepid water through the 
canal. It might be supposed that the tears during this 
time would flow entirely over the cheek; but this is not 
the case; they pass by the sides of the probe and moisten 
the nostril. Very little inconvenience is sustained by 
the patient in wearing the style constructed by Mr. 
Ware, and it occasions no more deformity than a small 
black patch. In six weeks sometimes the obstruction 
will be permanently removed, but as it occasionally re- 
curs even when the style has been continued a greater 
length of time, I have been accustomed to direct its use 
for six months. Some of Mr. Ware's patients have 
worn it for years, all the tears passing by its side into 
the nose. A great advantage is derived by gradually 
increasing the thickness of the style. Dr. Physick em- 
ploys three or four in succession, the last being double 
the thickness of the first. 

Mr. Ware directs, if the disease has not yet occasion- 
ed an aperture in the lachrymal sac, or if this aperture 
be not situated in a right line with the longitudinal 
direction of the nasal duct, a puncture to be made into 
the sac at a small distance from the juncture of the pal- 
pebrae, and nearly in a line drawn horizontally from 
this juncture towards the nose, with a very narrow 
spear-pointed lancet. The orifice thus formed soon be- 
comes fistulous round the style, and no irritation is ex- 
perienced in the subsequent introductions of this in- 
strument. 

VOL. I. ^ 



338 ELEMENTS OP SURGERY. 

When the ductus ad nasum is completely obliterated, 
instead of any attempt to form a new passage in the old 
situation, it is the practice to perforate the os unguis. 
Mr. Pott used a trochar for this purpose, but an incon- 
venience occasionally follows the use of the trochar ; the 
aperture closes up by the fragments of bone inflaming 
and reuniting ; to obviate this, Mr. Hunter constructed 
an instrument like a shoemaker's punch, by which a 
circular piece of bone may be cut out completely, and 
then the aperture cannot again be closed. It is true that 
a dossil of lint, or a probe of lead, or a bougie, kept in 
the passage will prevent its reuniting; but if Mr. Hun- 
ter's plan be adopted there will be no need of this trou- 
ble. Mr. Ware recommends a nail-headed style to be 
worn in this case, as well as in those instances where 
the natural canal is to be dilated, but for this practice I 
think there can be no necessity. 

The operation of removing a portion of the os unguis 
is very readily performed. The only necessary caution 
says Mr. Pott, " is to apply whatever instrument is used 
so that it may pierce through that part of the bone which 
lies immediately behind the sacculus lachrymalis, and 
not to push too far up into the nose, for fear of injuring 
the OS spongiosum behind, while it breaks its way." Mr. 
Hunter recommends a piece of thin smooth horn to be 
passed up the nostril, to receive the circular punch, 
which is to be passed into the lachrymal sac and forced 
through the os unguis, till it comes in contact witli the 
horn. When the perforation is completed, air passes 
out of the nose through the wound, and blood will flow 
through the wound into the nostril. The external open- 
ing may now be dressed with adhesive plaster and suf- 
fered to heal immediately. If carious bone exist it will 
be separated by the absorbents, and should fungus arise 
from the wound it is to be destroyed by caustic. Mr. 



ELEMENTS OF SURGERY. 33^ 

Ware's plan of introducing the style through the ductus 
ad nasum, and of continuing its use for a great length of 
time supersedes the use of this latter operation in all but 
a few rare instances in which there is coinplete oblitera- 
tion of the nasal duct. He is entitled to the greatest 
credit for his improvements in the treatment of this dis- 
ease. 



3^ ELEMENTS OF SURGERY. 

CHAPTER LVI. 

Of Cataract. 

By this term is designated an opacity of the chrystal- 
line lens or its capsule, or of both. The pupil of the 
eye, which is naturally perfectly black, becomes grey or 
white, except in some rare cases where it has a dark 
colour; the colour, however, is always distinguishable 
from the deep black of the pupil in a sound eye. In its 
commencement it occasions a weakness or dimness of 
sight, which increases until vision is totally destroyed. 
In general, cataract occurs in advanced life, seldom com- 
mencing before the age of forty ; in some cases, however, 
it begins much sooner, and is in some instances congeni- 
tal; in congenital cataract the capsule (according to Wen- 
zel and Saunders) is generally opaque and the lens fluid 
and milky. 

The causes of cataract are not very easily ascertained. 
Baron Wenzel found it most frequent among persons 
exposed to the light of strong fires, as blacksmiths, glass- 
blowers, &c. It now and then happens from external 
violence. 

The disease generally commences without pain; the 
first symptom is commonly an appearance of motes, 
specks, cobwebs, or insects floating before the eye; the 
patient attempts to remove them, but without eifect. The 
pupil at this time does not generally evince any morbid 
appearance, but as the disease advances, a settled mist 
or cloud obscures every object — vision is greatly impair- 
ed, and a turbid whitish appearance of the pupil begins 
to be observed. In some cases these symptoms proceed 
very slowly, and iu others the entire obfuscatioa of the 



ELEMENTS OF SURGERY. 34 j 

lens takes place in a few weeks. When the disease is 
fully formed the patient is generally able to discern the 
situation of a strong light; can distinguish day from 
night ; or perhaps count the windows in a room, but is 
unable to discern most objects, and in some cases even 
this faint degree of vision does not exist. 

In the incipient stage of the disease it is proper to em- 
ploy certain remedies which are occasionally useful in 
preventing its formation. Bleeding, purging, and a low 
diet, are to be recommended ; mercury has been supposed 
useful; setons, issues, and blisters, are also to be employ- 
ed. In some cases, more especially where the disease 
has resulted from external injuries, these remedies have 
been found successful, and the opacity has been removed 
by absorption ; but in general no such favourable termi- 
nation is to be expected, and Wenzel declares that ^^ in- 
ternal remedies either of the mercurial or of any other 
kind, are inadequate to the cure of this disorder, and 
equally so whether opacity be in the chrystalline or 
in the capsule, whether incipient or advanced." This is 
not quite correct; I have seen one patient in whom the 
lens or its capsule was universally opaque, and the pupil 
perfectly white ; and this opacity subsided in the course 
of four or five months ; the chief remedies employed were 
bleeding, purges, and mercury ; how far they were ser- 
viceable I am not able to determine, for Pott and Hey 
both remark that cataract from external violence some- 
times subsides spontaneously — the case alluded to was 
consequent to a wound of the eye. 

Mr. Ware believes in the occasional absorption of the 
opaque chrystalline, and recommends to expedite it, by the 
application of a drop or two of lether to the ball of the eye 
once or twice a day, together with friction over the eye- 
lid with a finger smeared with mercurial ointment. Lit- 
Ue confidence is to be placed in such remedies, and it is 



34^ ELEMENTS OF SURGERY. 

now \tvy generally conceded that the only method of 
restoring sight to persons afflicted witli cataract, is to 
remove tlie opaque chrystalline from the axis of vision; 
this may be done either by extracting it, or by depress 
sing it to the bottom of the eye. Both of these opera- 
tions are performed by sargeons of the present day, and 
each has powerful advocates among the most respectable 
members of the medical profession. Other operations 
have recently been invented for the cure of cataract which 
shall be described presently. 

Before comparing the merits of the two operations, it 
will be propyl' to enquire what cases of cataract promise 
to terminate successfully. Scarpa observes, " it is easy 
to determine whether an operation can be performed with 
a prospect of success or not. A favourable issue may be 
expected whenever the cataract is simple, or without any 
other disease of the eye-ball ; in a subject not quite un- 
healthy or decrepid, and in whom the opacity of the 
chrystalline humour has been gradually formed without 
having originated from any external violence, or habitual 
ophthalmia, especially the internal ; where there has not 
been frequent pain in the head, eye-ball, and superci- 
lium ; where the pupil, notwithstanding the cataract, has 
preserved its free and quick motion, as well as its circu- 
lar fignre in diiferent degrees of light; and lastly, where 
notwithstanding the opacity of the chrystalline lens, the 
patient retains the power, not only of distinguishing light 
from darkness, but also of perceiving vivid colours, and 
the principal outlines of bodies which ai'e presented to 
him, and where the pupil has that degree of dilatation 
which it is usually found to have in a moderate light." 

When the pupil does not contract and dilate in various 
degrees of light, there is reason to apprehend gutta serena 
(paralysis of the optic nerve and retina) but in some 
cases of gutta serena, even in both eyes this conti'actility 



ELEMENTS OF SURGERY. 34,3 

of the iris exists, and on the other hand, cases have oc- 
curred where no motion could be observed in the pupil? 
in which, nevertheless, the operation of extraction has 
proved the retina to possess its power of vision as usual ; 
the probable cause of the immobility of the pupil in these 
cases, is adhesion between the posterior surface of the iris 
and tiie anterior portion of the capsule of the chrystalline 
lens. These are to be considered however very rare ex- 
ceptions to a general rule. 

In distinguishing gutta serena from cataract, the colour 
of the pupil is to be considered ; it is black in the former 
disease, and turbid and lighter coloured in cataract ; but 
Wenzel has met with black cataracts, in which scarcely 
any change could be detected in the colour of the pupil. 
Both Wenzel and his commentator, Mr. Ware, believe 
it possible to distinguish the blackness of a cataract from 
the natural blackness of the pupil. Ue Haen and Van 
Swieten have been mistaken, yet they were not professing 
oculists. Mr. AVare decides boldly that " it is a rule 
as certain as almost any in surgery, that Avhen an eye in 
a state of blindness, is accompanied with a clear black 
pupil which is incapable of varying its size according to 
the degi-ee of light to which the eye is exposed; this 
blindness is produced by a defect of sensibility in the im- 
mediate organ of vision, and removable only by the ap- 
plication of proper stimuli to rouse it again to its natural 
action." 

To ascertain with precision the nature and consistence 
of a cataract by examination is perhaps impossible. 
Scarpa says " all that has been liitherto written and 
taught upon this subject, has not that degree of certain- 
ty which can serve as a guide in practice, and the most 
experienced oculist of the present day is not able to de- 
termine with precision what the nature and consistence 
of the cataract is, upon which he proposes to operate, nor 



g^ ELEMENTS OF SURGERY. 

whether the capsule be yet transparent or not, although 
the lens be evidently opaque. For it is an indisputable 
fact, that the capsule sometimes preserves its transpa- 
rency when the lens does not. The want of accurate 
notions however, upon this subject does not materially 
influence the success of the operation, as the surgeon 
ought in every case to be prepared to employ such means 
as the particular species of cataract which presents itself 
to him, may require during the performance of the opera- 
tion, whether hard or soft, accompanied by opacity of the 
capsule which invests it, or not. The firm chrystalline 
cataract undoubtedly admits of being more easily removed 
by the needle from the axis of vision tlian any other ; 
and does not rise again to its former place, if the surgeon 
in removing it from the pupil, use the precaution of bury- 
ing it in the vitreous humour. The soft, the milky, or 
the membranous cataract, however, when met with in the 
operation, may be also removed from the pupil, effused 
or lacerated with the same needle, without the necessity 
of introducing any other instrument into the eye." 

In the next place it will be proper to compare the ad- 
vantages of EXTRACTION and DEPRESSION as remedies for 
cataract. Scarpa says truly that '* in the warmth of dis- 
cussion the advantages of the one, and the disadvantages 
of the other, have been exaggerated by both parties." 

The most ancient of these operations is depression or 
couching. The extraction was not performed till near 
the conclusion of the seventeenth century. Freytagius 
Lotterius, and Wenzel, are the principal surgeons con- 
cerned in contriving and perfecting the operation of ex- 
traction. The last named oculist had wonderful success 
in the latter part of his life (though he confesses that he 
spoiled a " hat full of eyes" before he learned how to 
operate) and his son who succeeded him, was also ex- 
tremely celebrated. He remarks in his treatise that " the 



ELEMENTS OF SURGERY. 3^5 

accidents which are charged upon the operation of ex- 
traction may be reduced to the eight following ;— first, 
the staphyloma ;— secondly, pain ;— thirdly, the discharge 
of the vitreous humour ; — fourthly, the irregularity of the 
pupil ;— fifthly, the deformity of the cicatrix ; — sixthly, 
the closure of the pupil ; — seventhly, the secondary cata- 
ract; and eighthly, the section of the iris. 

First. With regard to the staphyloma; Wenzel re- 
marks " that the mode in which the cornea is divided 
most commonly prevents this accident, by hindering the 
iris from coming forwards. But if such an accident 
should at any time happen, notwithstanding this care to 
prevent it, it may be reduced by merely rubbing the eye- 
lids ; and it does not occasion those ill eflPects which 
some authors have dreaded. 

Secondly. The unavoidable pain that attends the ope- 
ration of extraction is to be moderated, as in other opera- 
tions by general remedies. It is, however, notwithstand- 
ing the assertion of a late author, less severe than that 
which is produced by depression. 

Much has been said respecting the comparative pain 
of the two operations: I do not consider it an object of 
gi-eat magnitude to decide this contest, because it must be 
conceded on all hands that if an important advantage is 
to be gained by a temporary addition to the sufferings of 
the patient, this slight evil should not enter into compe- 
tition with a permanent benefit; and it is notorious to all 
who are conversant with the subject, that neither couch- 
ing or extraction, are to be considered as very painful ope- 
rations. Notwithstanding this, from what I have seen, 
and I have seen very numerous cases where extraction 
has been performed, and some cases of couching, I am 
very decidedly of opinion that coucliing is the more pain- 
ful operation. One patient in particular I recollect who 
had been couched, and whose cataract had resumed its 

VOL. I. ^^ 



315 ELEMENTS OF SURGERY. 

situation, wbeu the operation of extraction was fiiiislieil 
(whicli was performed on the other eye) exclaimed, " is 
it possible the operation is over ? it was not half so severe 
as the couching.*^ I have never heard a single patient 
complain of much pain during the extraction of a cataract, 
but have often heard them express great astonishment at 
having suffered so little. 

Thirdhj. The escape of the vitreous humour if the ope- 
ration be properly performed, will seldom take place. lu 
some cases, however, notwithstanding every caution, por- 
tions of this fluid will escape. Wenzel thinks that al- 
though this is a sliglit evil, yet the clear perception of oh- 
jects is sometimes diminished by this accident ; but I 
have known a very considerable quantity of vitreous hu- 
mour lost in several instances, in which not the slightest 
inconvenience resulted, but the cure Avas perfected as well 
as in the most successful cases. This is therefore no ob- 
jection to the operation of extraction ; first, because the 
escape of vitreous humour can generally be prevented ; 
and secondly, if from its unusual fluidity, or any other 
cause, a portion of it should escape, no harm results from 
its loss. 

Fourthly. An irregularity of the form of the pupil is 
an occasional consequence of the extraction of a cataract, 
— but I would observe tliat it is a very rare accident, and 
of little moment when it occurs. The shape of the pupil 
is of no great consequence, and though I do not agree 
with Wenzel that it becomes an advantage by enlargin"* 
the aperture through which the rays of light are to pass, 
yet I do maintain that patients see as well in whom some 
irregularity of the pupil exists, as they in whose eyes the 
pupil is a perfect circle. 

Fifthly. The cicatrix of the cornea. « If the incision 
be made with one instrument and one stroke, if it be near 
the margin of the sclerotica and large enough to allow the 



ELEMENTS OF SURGERY. g^r 

©paque chrystalline to pass through it without violence ; 
in this case the cicatiix will be scarcely visible and will 
not at all obstruct the rays of light in their passage to the 
retina.'^ AVhen the incision is made originally toosmall 
and is enlarged by means of scissors, the cicatrix becomes 
opaque, but if it be near tlie sclerotica it does not, even if 
opaque, interfere with vision. In general it is impossible 
to discern a vestige of the wound made in the cornea. 

Sixthly. A total closure of the pupil. This I never 
saw, and Wenzel asserts that it is much more frequent 
after couching: certainly the iris is often scratched and 
injured by the needle used in the latter operation, and of 
course is liable to inflammation from which this closure 
generally arises. 

Seventhly. A secondary cataract, or opacity of the 
capsule of the lens. This happens both after extraction 
and couching, and I know net which it most frequently 
succeeds ; Wenzel of course says it is most common after 
couching. One thing is certain, that if the capsule be 
found opaque it is easily removed at the same time with 
the lens ; if it become opaque afterward, a repetition of 
the section of the cornea will readily enable the surgeon 
to extract it. 

Eighthly. A wound of the iris by the edge of the knife. 
This accident it is generally in the power of the surgeon 
to prevent. It commonly arises (except in awkward 
hands) from an escape of a small portion of aqueous hu- 
mour at the puncture made by the knife in passing through 
the cornea ; whenever the iris is found floating before the 
edge of the knife, as in (Fig. 11.) a gentle friction should 
be made upon the cornea with one finger of the hand 
which is at liberty, and the iris in this way becomes dis- 
engao-ed from the edge of the knife. Whether the fric- 
tion acts by stimulating the iris to contract or whether by 
pressure' on the cornea the iris is stretched at its margin. 



348 ELEMENTS OF SURGERY. 

and thus mechanically disengaged, is not easily ascertain- 
ed. Mr. C. Bell (without much experience in the ope- 
ration) recommends pressure, and gives what he calls 
" an intelligible reason" for it. The fact is that friction 
succeeds immediately in reducing the iris to a situation 
behind the knife, and how this is effected is of no sort of 
consequence. 

Mr. Hey for whose judgment in common with the me- 
dical world, I entertain a very high respect, differs with 
Ware and Wenzel, and prefers the operation of couch- 
ing to extraction. Scarpa who has attended with great 
diligence to the subject, prefers couching ; and to such 
authority great deference is unquestionably to be paid. 
Each of these gentlemen has invented a couching needle 
different from that in common use, and never perform 
any other operation than depression. 

Scarpa has offered no defence of couching, but round- 
ly asserts that " observation and experience, the great 
teachers in all things, seem to have decided in fa- 
vour of the ancient method of treating the cataract, or 
that by depression." Mr. Hey on the contrary, enters 
into a laboured vindication of the operation, against the 
attack of Baron Wenzel. 

The Baron alleges against couching many evils which 
probably in the hands of Scarpa or Hey, never have oc- 
curred, and like most other disputants has urged his ob- 
jections in language too strong and general. 

The consequences to be dreaded from couching he 
states under eight distinct heads ; firsts great pain at the 
time of the operation and subsequently to it ; second, vo- 
miting from a wound of the ciliary nerves, occasioning 
collections of matter ; thirds pain and suppuration of the 
eye from puncturing the retina ; fourth, violent long con- 
tinued pain in the eye, sometimes during life; ffth, 
bleeding into the cavity of the eye occasioning suppura- 



ELEMENTS OF SURGERY. 3^g 

tion ; sixth, the impossibility of depressing fluid or milky 
cataracts ; seventh, tlie rising again of the lens;* eighth, 
wounding the ciliary processes. Enlarging on these ideas 
Wenzel very strongly contends in favour of extraction, 
and Mr. Hey taking up each of the arguments very in- 
geniously endeavours to refute them, and states that the 
pain in couching is very triiling ; — that the vomiting sel- 
dom occurs, and when it does, is removed by an opiate ; — 
that suppuration of the eye — that the long continued pain 
and bleeding within the eye, he never has met with in 
his practice. 

The milky cataract Mr. Hey declares ^^ has in some 
respects the advantage over a hard one, as the former is 
less apt to adhere to the iris, and consequently there is 
less risk of deranging the ciliary processes or their invest- 
ing membrana nigra, by breaking down a soft cataract 
than by removing a hard one." Mr. Hey confesses, how- 
ever, that " the softness of the cataract generally requires 
a repetition of the operation but does not prevent the pa- 
tient from receiving a cure." The objection that the ca- 
taract if depressed is liable to rise again, Mr. Hey admits 
to be " true, but of little consequence. A repetition of 
the operation is not in this case always necessary, as the 
chrystalline will sometimes spontaneously subside and 
disappear, and when it does not, a repetition of the ope- 
ration has never failed within the compass of his expe- 
rience of being attended with success." 

The wound of the ciliary processes, Mr. Hey prevents 
by a change in the shape of the needle which instead of 
being spear-pointed should be square. 

Mr. Hey further states that the opaque capsule though 
it cannot be depressed may be so lacerated by the nee- 
dle as soon to be absorbed. Mr. Hey does not believe 

• The lens has been found undissolved seventeen years after coacirm?^ 



350 ELEMENTS OP SUltGERY, 

with the Baron that a closure of the pupil or an opacity 
of the capsule of the lens, are to be considered as solid 
objections against couching. 

Mr. Hey when he quits his defensive attitude, and at- 
tacks the operation of extraction by replying to Baron 
Wenzel and Mr. Ware, in their account of its advan- 
tages, appears by no means a powerful opponent. Unit- 
ing with Mr. Hey in the sentiment with which he closes 
his chapter upon cataract, I can declare with truth my 
wish " that that mode of operating may prevail which is 
most beneficial to the afflicted.'' I have no hesitation in 
deciding from what I have seen and read, and from hav- 
ing myself performed the operation (though not frequent- 
ly) that extraction in a great majority of cases, ought to 
be performed in preference to couching, and I have no 
doubt that its advocates would be much more numerous, 
if the operation were as easily performed, for the greatest 
advantage which I conceive couching to possess is the fa- 
cility with which it is done ; it is in fact an operation, re- 
quiring very little dexterity or science, I shall describe 
both operations. 



ELEMENTS OF SURGERY. ggi 

CHAPTER LVII. 

Of Extraction. 

It will geiierallj be proper that the patient for a week 
before the operation be confined to a low diet— he should 
be free from catarrh and other diseases — coughing, sneez- 
ing, or vomiting w ould prove extremely pernicious after 
tlie operation. The seasons to be preferred are the spring 
and fall, when the weathei- is settled and mild. 

The instruments necessary in the operation of extrac- 
tion are a knife for dividing the cornea ; the one to be 
preferred is the instrument invented by the elder Wenzel. 
" It resembles the common lancet employed in bleeding, 
except that its blade is a little longer and not quite so 
broad. Its edges are strait. The blade is an inch and a 
half long and a quarter of an inch broad, in the widest 
part of it, which is at the base. From hence it gradually 
becomes narrower towards the point, so that this breadtli 
of a quarter of an inch extends only to the space of about 
one-third of an inch from the base, and for the space of 
half an inch from the point, it is no more than one-eighth 
of an inch broad." 

One edge is sharp through the whole length of the 
blade, at the distance of a quarter of an inch from the 
base, this lower edge has a slight projection. The up- 
per edge is divided into three portions for the space of 
five-sixths of an inch from the basis ; this edge is blunt, 
and very little flattened. For the space of half an inch or 
rather six lines and a half* further towards the point, it 
is blunt and rounded, although very thin. The extremity 
of this edge to the extent of one-eighth of an inch from the 

• A line is llie twelfth part of aii inch. 



353 ELEMENTS OF SURGERY. 

point, is keen like the lower edge, in order to facilitate 
the conveyance of the instrument througli the cornea — 
the handle is octangular. The knife is represented in 
Fig. 14. 

I have described it particularly, because much of the 
success of the operation depends upon the perfection of 
the instrument. Mr. Ware uses a knife very little dif- 
ferent from WenzePs ; it is rather wider near the point, 
in order that the edge may quickly get below the infe- 
rior margin of the pupil and thus avoid wounding the 
iris. 

It has been customary in operating on the eye to make 
use of a contrivance called a speculum to keep the eye 
motionless ; a variety of specula have been constructed, 
but in the opinion of Baron Wenzel they are useless. In 
addition to the knife, a curette, or small scoop of silver 
or gold, and a curved needle of steel which are gene- 
rally fixed to one handle (Fig. 15.) ; — a small steel hook 
(Fig. 13.) ; — and a pair of small forceps (Fig. 16.) are 
all the instruments required for the operation. Instead 
of the forceps copied from Wenzel, a more convenient 
form is that delineated (Fig. 4.) the extremities are to 
be fiat, and their surfaces of contact when closed about 
the fourth of an inch. 

OPERATION. 

The patient is to be seated in a low chair before a mo- 
derate light which strikes the eye obliquely. Baron 
Wenzel directs the operator to proceed in the following 
manner. 

" The sound eye being covered with a compress re- 
tained by a bandage, an assistant, placed behind, must 
hold the patient's head, and support it on his breast. 
With the fore-finger of the hand that is at liberty, he is 
then to raise the upper lid of the eye to be operated upon, 



ELEMENTS OF SURGERY. ^^ 

and gently to press the tarsus, with the extremity of the 
finger, against the npper edge of the orbit. In order to 
assist this arrangement, and properly to fix the upper 
lid, the assistant should take care to draw up the skin 
over the orbit, and strongly to fold the teguments that 
support the eye-brow. By this method, the eye will be 
entirely uncovered, an undue pressure upon it will be 
avoided, the fingers of the assistant will not interfere 
with those of the operator^ and the eye-lid will Ue so 
fixed as to be incapable of any motion. 

"The operator is to be seated on a chair, a little 
higher than that bf the patient. The eyes naturally 
turning towards the light, he is to place the head of the 
patient obliquely to a window ; so that the eye to be 
operated upon may be inclined towards the outer angle 
of the orbit. This position of the eye will enable the 
operator to bring out the knife, on the inner side of the 
cornea, opposite to the part where it pierces this tunic, 
more exactly than he would otherwise be able to do. 
The operator is to rest his right foot on a stool, placed 
near the patient, that his knee may be raised high enough 
to support the right elbow, and to bring the hand with 
which he holds the knife, to a level with the eye on 
which he is to operate : (this direction I think unne- 
cessary if the operator have a steady hand.) He is then 
to take the cornea knife in his right hand, if it be the 
left eye on which he is to operate, and, vice versa, in 
the left hand, if it be the right eye. The knife is to be 
held like a pen in writing, and his hand is to rest stea- 
dily on the outer side of the eye, with the little finger, 
separated a little from the rest, on the edge of the orbit. 
Ill this position he is to wait, without any hurry to begin 
the incision, until the eye which is usually very much 
adtated by the preparations for the operation, becomes 
perfectly still. This always takes place within a few 
46 



VOL. I. 



354* ELEMENTS OF SURGERY. 

seconds of time; and, therefore^ as I have already fully 
expressed myself on this subject^ »every instrument in- 
vented to fix it is useless. 

^•' When the eye is still and so turned towards the outer 
angle of the orbit, that the inner and inferior part of the 
cornea, through which the point of the instrument is to 
come out, may be distinctly seen, the operator is to plunge 
the knife into the upper and outer part of the tunic, a 
quarter of a line distant from the sclerotica, in such a 
direction, that it may pass obliquely from above down- 
wards, parallel to the plane of the iris. At the same 
time, the operator must depress the lower lid with his 
fore an<l middle fingers, which are to be kept a little 
distant one from the other, and must take the greatest care 
to avoid all pr.essure on the globe, which is to be left 
perfectly free, as the surest way to diminish its power of 
moving.* 

" When the point of the knife has proceeded so far 
as to be opposite to the pupil, it is to be dipped into this 
aperture, by a slight motion of the hand forward, in order 
to puncture the capsule of the chrystalline ;f and then by 
another slight motion, contrary to the former, it must be 
withdrawn from the pupil, and, passing through the an- 
terior chamber, must be brought out near the inferior part 
of the cornea, a little inclined to the inner angle, and at 
the same distance from the sclerotica, as when it pierced 
the cornea above. If the knife has been well-directed, 
and the fore and middle fingers of the hand opposite to 
that which holds the instrument, have been properly ap- 
plied, the section of the cornea, thus completed, will be 

* Mr. Ware very properly condemns this direction, and advises the eye at 
this time to be moderately pressed, which certainly serves to fix it, and pre- 
vent its motion. 

■J- Baron Wenzel's practice in tliis particular, is not to be imitated by any but 
experienced operators. 



ELEMENTS OF SURGERY. 355 

found suflBciently large ; its shape will be semi-circular ; 
and it will be quite near enough to the margin of ilye 
sclerotica." (Wenzel.) 

Wlien the iris is unusually convex^ and in making the 
section of the cornea becomes entangled before the knife, 
the cornea is to be rubbed downward with the linger, 
which disengages it. A fear of wounding the iris, should 
never induce the operator to make the section of the cor- 
nea at too great a distance from the sclerotica, because 
the section will in that case be too small to allow the lens 
to escape. 

While the section of the cornea is proceeding, and when 
the point of the knife has passed out at the side opposite 
to the part at which it entered, the assistant lets the upper 
eye-lid drop, and all pressure is immediately taken oflf. 

The next part of the operation consists in puncturing 
the capsule of the chrystalline lens, for I believe few 
surgeons have dexterity and confidence enough to do it, 
generally, with the cornea knife. The best mode of ef- 
fecting this will be to introduce the needle (Fig. 15.) 
through the wound in the cornea, into the pupil, and 
move it gently, but freely and quickly, in all directions; 
by this manoeuvre the anterior portion of the capsule will 
be lacerated, and a gentle degree of pressure being made 
upon the eye, the pupil is observed gradually to enlarge, 
and one edge of the lens is observed escaping through it ; 
all pressure is to be immediately removed, and the 
opaque chrystalline escapes. 

Sometimes it is necessary to assist its escape through 
the aperture in the cornea, by the use of the needle, or 
scoop, and any portion of opaque glutinous matter which 
remains behind are to be carefully removed by the cu- 
rette. If the capsule be not opaque the pupil will now 
be observed to have regained its natural blackness, and 
the patient will discover the surrounding objects. la a 



350 ELEMENTS OF SURGERY. 

majority of the cataracts wliicli I have seen extracted, 
{he centre has been firm and dense, but portions of the 
external part have been soft and glutinous, and have re- 
mained after the extraction of the central portion. If it 
be inconvenient to remove them all, it will be better to 
wait f(n- their absorption than to augment the danger of 
inflammation by protracting the operation too long. 

Sometimes the cataract, according to Weuzel, adheres, 
and must be separated by the needle from its adhesions, 
this is in general readily ejffected by inserting the needle 
in the lens, and moving it gently in different directions. 

If the capsule of the lens be found opaque, it may now 
be extracted, by means of a pair of small forceps ; those 
recommended by Wenzel, (Fig. 16.) are much too clumsy, 
they cannot, from their bulk, be readily opened and shut 
in the wound of the cornea, it is more convenient to have 
forceps resembling those delineated in Fig. 4. 

The anterior portion of the capsule is most frequently 
opaque, and sometimes considerably thickened and indu- 
rated; when this is the case it comes out at once ; if it be 
torn, however, the fragments are to be removed, and dur- 
ing this part of the operation, great care must be taken to 
avoid the escape of the vitreous humour; the eye should 
not be kept open long at a time, and the attempts to ex- 
tract the portions of opaque capsule, should be repeated 
as often as necessary, but not continue more than a minute 
at a time, and the eye in the intervals should be covered 
with a small compress of fine linen wet with clear cold 
water. 

Dr. Physick has, in some cases where the capsule was 
evidently opaque, extracted it first with the forceps ; when 
this is done the lens descends below its usual situation, 
but its falling to the bottom of the eye " does not appear 
to be quite correct ; it was in the cases alluded to, very 
easily extracted with a curved needle, or small hook, 



ELEIMEXTS OF SURGERY. 35~ 

(Fig. 13.) this hook is occasionally useful in removing 
portions of the capsule as well as of the lens and should 
always be at hand. 

The lens does, however, in a diseased state of the 
vitreous humour, descend in some cases to the inferior 
part of the eye, and in these cases pressure cannot be 
used, and it must be extracted with the hook. 

If the capsule though lucid at the time of the opera- 
tion should become subsequently opaque, forming what 
is called secondary cataract, the section of the cornea is 
to be repeated, and the opaque membrane removed. The 
subsequent treatment consists in preventing inflammation. 
The patient should lie on his back for eight or ten days, 
the room being somewhat darkened : the eye requires no 
dressing but a compress loosely applied : the hands ought 
in every instance to be secured to the sides of the bed by 
means of tapes, in such a manner as to prevent their 
reaching so high as the head, persons waking, are very 
apt to rub their eyes, and sight has been destroyed by 
such accidents, the caution just given ought therefore 
never to be neglected; a low diet, and if necessary from 
the accession of fever, bleeding and purging ought to be 
directed. 

For much useful information on the present subject, 
the reader is referred to the writings of Mr. Ware, and 
Baron Wenzel, 



358 ELEME3STS OP SUBGEBlT. 

CHAPTER LVIII. 

Of Couching. 

It has already been mentioned, that this operation 
consists in depressing the opaque chrystalline lens, and 
removing it from the axis of vision. The couching 
needles generally employed are those of Saunders, fig. 
5 ; of Scarpa, fig. 6 ; and of Hey, fig. 7- No very parti- 
cular description need be given. Scarpa's needle is, in 
my opinion, to be preferred; it possesses firmness enough 
to enter the eye without danger of its breaking, and has 
a point somewhat curved. The curved extremity is sharp 
at the edges, and polished and flat upon its convex dor- 
sum ; there is a mark on the side of the handle which 
corresponds to the convexity of the point. It should be 
made rather shorter than Scarpa directs. I shall quote 
the description given by this celebrated oculist of his 
operation. 

OPERATION. 

" Every thing being arranged for performing the ope- 
ration, the surgeon should place his patient on a low 
seat, on the side of a window which has a northern as- 
pect, so that the light coming from it may only fall upon 
the eye which is to be operated on laterally. The pa- 
tient's other eye being covered, although affected with 
cataract, the surgeon ought to place himself directly op- 
posite the patient, upon a seat of such a height, that 
when he is prepared to operate, his mouth shall be on a 
level with the patient's eye. And, in order to give his 
hand a greater degree of steadiness in the several mo- 



ELEMENTS OF SURGERY. 359 

tions which the depressions of the catai-act require, the 
elbow corresponding to this hand should be supported 
upon the knee of the same side, which for this purpose 
he should raise sufficiently by resting his foot upon a 
stool, and according to circumstances also, by placing a 
small hard pillow upon his knee. An able assistant si- 
tuated behind the patient, with one hand fixed upon the 
chin, should support the patient's head against iiis breast, 
and with the other placed on the forehead, gently raise 
the upper eye-lid by means of Pellier's elevator, care- 
fully observing to gather the eye-lid against the arch 
of the orbit, without pressing upon the globe of the 
eye. 

" Supposing then the eye to be operated on is the left, 
the surgeon taking the curved needle in his right hand, 
as he would a writing pen, with the convexity of the 
hook forwards, the point back, and the handle in a di- 
rection parallel to the patient's left temple ; should rest 
his fingers upon the temple, and boldly perforate the eye- 
ball in its external angle, at rather more than a line from 
the union of the cornea and sclerotica, a little below the 
transverse diameter of the pupil, gradually moving the 
extremity of the handle of the needle from beiiind for- 
wards from the patient's left temple, and consequently 
giving the whole instrument a curved motion, until its 
bent point has entirely penetrated the eye-ball ; which is 
effected with the greatest readiness and ease. The ope- 
rator should then conduct the convexity of the needle 
upon the summit of the opaque chrystalline, and by pressing 
upon it from above downwards, cause it to descend a lit- 
tle, carefully passing the curved point at the same time 
between the corpus ciliare and the capsule of the chrystal- 
line lens, until it be visible before the pupil, between the 
anterior convexity of the capsule of the lens and the iris. 
Having done this he should cautiously push the hook 



g50 ELEAfENTS OF SURGERY. 

with its point turned backwards towards the internal 
angle of the eye, passing it horizontally between the 
posterior surface of the iris, and the anterior convexity 
of the capsule, until the point of the needle has arrived 
as near the margin of the chrystalline and capsule as pos- 
sible, which is next the internal angle of the eye, and 
consequently beyond the centre of the opaque lens. The 
operator then inclining the handle of the instrument more 
towards himself, should press the curved point of it deep- 
ly into the anterior convexity of the capsule, and sub- 
stance of the opaque chrystalline, and by moving it in the 
arc of a circle, should lacerate the anterior convexity of 
the capsule extensively, remove the cataract from the 
axis of vision, and lodge it deeply in the vitreous hu- 
mour, leaving the pupil perfectly round, black, and free 
from every obstacle to the vision. The needle being re- 
tained in this position for a short time, if no portion of 
opaque membrane appear behind the pupil, which would 
require the point of the instrument to be turned towards 
it, in order to remove such obstacle, (for with respect to 
the chrystalline, depressed in the manner now described, 
it never rises again) the surgeon should give the instru- 
ment a small degree of rotatory motion, in order to dis- 
entangle it easily from the depressed cataract, and should 
withdraw it from the eye in a direction opposite to thf^t 
in which it had been introduced, that is greatly in- 
clining and turning the handle towards the patient's left 
temple. 

" In every species of cataract, with considerable opa- 
city and density of the anterior hemisphere of the cap- 
sule of the chrystalline, the surgeon may very easily know 
during the operation, whether the curved point of the 
needle, insinuated between the corpus ciliare and the cap- 
sule, is exposed between the pupil and the anterior he- 
misphere of that membrane; or, whether having pene- 



ELEMENTS OF StRGERY. ggi£ 

trated iuto the membranous sac of the chrystalline, it has 
only advanced between the anterior hemisphere of the 
capsule and the opaque lens. But Avhen tbe capsule, not- 
withstanding the opacity of the chrystalline lens, pre- 
serves in a great measure, or entirely, its transparency, 
it is an easy matter for a young surgeon, not suificieutly 
conversant with this operation, to commit an error, and 
one of great importance, that is, to remove the cataract 
from the axis of vision, and lodge it in the vitreous hu- 
mour, leaving the anterior convexity of the capsule un- 
touched, which afterwards gives rise to the secondary 
membranous cataract. 

'^ To avoid this serious inconvenience, every operator 
shoulcf be particularly careful to satisfy himself before 
making any movement with the point of the needle for 
depressing the cataract, that the curved extremity of the 
instrument is really, and not apparently, situated between 
the pupil and the anterior portion of the capsule, of 
which he will be convinced by the degree of light which 
the convexity of the hook presents to him, and the faci- 
lity which he finds in pushing it forwards through the 
pupil towards the anterior chamber of the aqueous hu- 
mour, and in moving it horizontally between the iris and 
anterior hemisphere of the capsule. In the opposite case 
he may be certain that the curved point is within the 
membranous sac of the chrystalline, by observing that the 
extremity of the needle is obscured and covered by a 
more or less transparent veil ; that he meets with some 
resistance in pushing it through the pupil into the ante- 
rior chamber of the aqueous humour ; and that in doing 
it, this membranous veil which covers the hook is ele- 
vated towards the pupil, and lastly, that the point of the 
needle is with difficulty conducted horizontally between 
the iris and the cataract, from the external towards the 
internal angle of the eye. 

VOL. I. 47 



363 ELEMENTS OF SURGERY- 

" The surgeon will remedy this inconvenience, by 
giving a slight rotatory motion to the needle, by which 
the point being forwards will pass through the anterior 
convexity of the capsule opposite the pupil ; the point of 
the instrument being then turned backwards again, should 
be passed horizontally between the iris and the anterior 
hemisphere of the capsule towards the internal angle of 
the eye, and having reached this part should be boldly 
plunged into the capsule, and the substance of the opaque 
lens, in order to lacerate the former extensively, and to 
earry the latter deeply into the vitreous humour out of 
the axis of vision, and thus complete the operation. 

"^ When, without observing this precept, the opaque 
lens is removed, or, more strictly speaking, enucleated 
from its capsule and lodged in the vitreous humour ; and 
the anterior convexity of this membrane being left entire, 
is slightly opaque, the pupil will appear black, and so 
free from obstruction to the light as easily to deceive the 
young surgeon, and induce him to believe tliat the ope- 
ration has been properly executed. But persons expe- 
rienced in this part of surgery, will instantly perceive 
that the pupil under such circumstances, has not that just 
and perfect degree of blackness which it ought to have, 
and that this slight dimness is caused by an imperfectly 
transparent membranous veil, placed between the pupil 
and the bottom of the eye, which when suffered to re- 
main, never fails, in process of time, to give rise to the 
secondary membranous cataract. In this case, the expert 
operator having depressed the opaque lens, should im- 
mediately turn the curved point of the needle forward, 
and pass it through the pupil into the anterior chamber of 
the aqueous humour, in order to perforate this semi-trans- 
parent membranous veil with the greatest certainty ; then 
turning the point of the needle backwards and making it 
pass as far as possible between the posterior surface of ^ 



ELEMENTS OF SURGERY. 3(^3 

the iris and this membrane, should press tlie point of the 
instrument into it and lacerate it from before backwards, 
making a movement as if he had to depress the lens 
again. In doing tliis he will have the satisfaction to see 
the pupil assume tlie deep black colour of velvet, and a 
degree of clearness which it had not before, although the 
opaque lens had been completely removed from the axis 
of vision. 

"^ Hitherto I have supposed the cataract to be of a firm 
consistence, and to resist tlie pressure of the needle. But 
if the operator should meet with a fluid cataract, the 
milky for instance, which is not an unfrequent occurrence, 
when he has passed the needle between the corpus ci- 
liare and the capsule, until it appears uncovered between 
the pupil and the anterior hemisphere of the membranous 
sac of the chystalline lens, and the curved point has been 
cautiously advanced between the iris and the margin of 
the capsule, nearest the internal angle of the eye ; at the 
moment that the point of the needle is deeply pressed 
into the capsule and cataract, a whitish milky fluid will 
be seen to issue from the capsule, which extending itself 
in the form of a cloud or smoke, will be diffused through 
both the chambers of the aqueous humour, and obscure 
the pupil and the whole of the eye. The surgeon should 
not on this account lose his confidence, but, guided by 
his anatomical knowledge, should make the small hook 
describe the arc of a circle from the internal towards the 
external angle of the eye, and from before backwards, as if 
he were depressing a solid cataract, with a view of lacerat- 
ing* as much as possible, the anterior hemisphere of the 
capsule, upon which the favourable success of the opera- 
tion principally depends, not only in this, but in every 
other species of cataract. For as to the effusion of the 
milky fluid into the chambers of the aqueous humour, it 
disappears spontaneously a few days after the operation, 



364 ELEMENTS OF SURGERY. 

and permits the pupil and the whole of the eye to resume 
their former natural brightness. 

" The method of operating which the surgeon should 
employ will be little diflferent from this, if, during its 
performance, he should meet with a soft or cheesy ca- 
taract. Tiie anterior convexity of the capsule should be 
lacerated as much as possible opposite the pupil, so that 
the opening may equal the diameter of the pupil in its or- 
dinary dilatation. And with respect to the pulpy sub- 
stance of the cataract, which, in such cases, remains be- 
hind, partly diffused in the aqueous humour, and partly 
swimming beyond the pupil, all that is necessary, is to 
divide the most tenacious parts of that substance, that 
they may be more easily dissolved in the aqueous hu- 
mour, and to push those moleculse of the caseous sub- 
stance of the chrystallme, which cannot be sufficiently di- 
vided, through the pupil into the anterior chamber of the 
aqueous humour, in order that they may not be carried 
opposite the pupil, but being situated at the bottom of the 
anterior chamber, may be gradually dissolved and ab- 
sorbed without obstructing the sight." (Scarpa.) 



ELEMENTS OF SURGERY. gQg 

CHAPTER LIX. 

Of Congenital Cataract. 

The late Mr. Saunders of London, instituted an in- 
firmary for the reception of patients afflicted with diseases 
of the eyes— he lived but a few years after its founda- 
tion, long enough however, to be very useful as surgeon 
to the establishment, and a small posthumous volume 
published in 1811, contains a number of highly interest- 
ing remarks on various aifections of this important organ. 
The following observations on congenital cataract are ex- 
tracted principally from his writings. 

The causes of congenital cataract are unknown : it ap- 
pears sometimesinseveralof the same family. Mr. Saun- 
ders saw sixty cases of the disease between June 1806, 
and December 1809, so that it is by no means unfrequent. 
He relates many cases where several children of the same 
parents were born blind. 

The opacity is generally seated in the capsule ; the 
lens being absorbed. Sometimes the lens is opaque, and 
solid or fluid as in adults. Mr. Saunders found that the 
only treatment necessary, was to perforate the centre of 
the capsule, and if a permanent aperture was made in that 
membrane, the lens if it existed was subsequently ab- 
sorbed. 

Children affected with the disease possess various de- 
grees of vision. Some indistinctly see external objects, 
others can only discern bright colours or vivid lights. If 
the privation of vision be nearly complete, volition for 
want of an external object to attract these organs, is not 
exercised over the muscles belonging to them; and their 



2(56 ELEJtfENTS OF SURGERY. 

actions are not associated, but t]ie eye rolls here and 
there with rapidity, and trembles as it moves. 

The excessive mobility of the eye, the unsteadiness of 
the little patient, the small iield for the operation, and 
tlie flexi!>ility of the opaque capsule, are the difficulties 
with which the surgeon has to contend. Mr. Saunders 
overcame them by fixing the eye-ball with a speculum, 
controlling the patient, dilating the pupil with belladon- 
na, and by using a diminutive needle armed with a cut- 
ting edge from its shoulders to its point, and thin enough 
to penetrate with the most perfect facility. This needle 
is delineated in Fig. 5. 

The extract of belladonna is to be diluted with water 
to the consistence of cream and dropped into the eye, 
or the extract undiluted may be smeared over the eye- 
lid and brow. In half an hour, or an hour the pupil is 
fully dilated, and the application should be then washed 
off. The patient is confined in a proper position and in 
a situation near a window by a sufficient number of as- 
sistants, who take great care to fix the head motionless, 
and to secure the limbs from moving. The operator is 
seated on a high chair, behind the patient, takes the spe- 
culum in one hand and the needle in the other. 

Should the capsule contain an opaque lens, the sur- 
geon gently introduces the bow of the speculum under 
the upper eye-lid, his assistant at the same time depress- 
ing the lower, and at the moment he is about to pierce 
the cornea, he fixes the eye by resting the speculum with 
a moderate pressure upon the eye-ball. The position of 
the operator enables him to do this with perfect safety, 
and by that consent which can only exist betv»'eeu the 
hands of the same person, he not only discontinues the 
pressure, by using the speculum merely as an elevator 
of the lid, as soon as his purpose is accomplished, but 
he with facility renews or regulates the pressure at any 



ELEMENTS OF SURGERY. 3^^ 

moment in which it may be required. He penetrates the 
cornea as near to its junction with the sclerotica as it 
will admit the flat surface of the needle to pass, in a di- 
rection parallel and close to the iris, without injuring this 
membrane. When the point of the needle has arrived 
at the centre of the dilated pupil, he does not boldly 
plunge it through the capsule into the lens, and perform 
any depressing motion ; it is a material object with him 
not to injure the vitreous humour or its capsule ; neither 
does he lift the capsule of the lens on the point of the 
needle, and by forcibly drawing it forward into the an- 
terior chamber, rend it through its whole extent. Such 
an operation would dislocate the lens, deliver it into the 
anterior chamber, or leave it projecting in the pupil, and 
stretching the iris ; and although its soft texture in the 
child should exempt him from any disorganizing in- 
flammation, the most favourable result will be a perma- 
nently dilated iris, deforming the eye. He proceeds 
with a gentle lateral motion, working with the point and 
shoulders of the needle only on the surface and centra 
of the capsule, in a circumference which does not ex- 
ceed the natural size of the pupil. This object is per- 
manently to destroy this central position of the capsule : 
merely to pierce it would not answer his intention, be- 
cause the adhesive process will speedily close the wound. 
Having acted upon the centre of the anterior lamella of 
the capsule to the extent which he wishes, he gently 
sinks the needle into the body of the lens, and mode- 
rately opens its texture. In doing this he may, if he 
pleases, incline the edge of the needle, by which motion 
the aqueous humour vv'ill escape, and the lens will ap- 
proach his instrument; but at the same time his field for 
operating will be diminished by the contraction of the 
pupil. The needle and speculum are now to be with- 
drawn, the eye is to be lightly covered, and the patient 
put to bed. 



368 ELEMENTS OF SURGERY. 

Inflammation is seldom excited by this operation ou 
the child ; but its first appioachj marked by pain and 
unusual redness of the conjunctiva, or serous effusion 
under it, must immediately be arrested by the applica- 
tion of leeches on the palpebrae, and, in stouter children, 
by bleeding from the arm, followed by purgatives and a 
very low diet. Soon after the operation the extract of 
belladonna should be applied over the eye-brow, to pre- 
vent, by a dilatation of the iris, the adhesion of the pupil- 
lary margin to the wounded capsule. Nature now per- 
forms her part of the cure, and the lens, loosened in its 
texture, and through the aperture in the capsule, sub- 
jected to the action of the aqueous humour, is gradually 
dissolved and absorbed. 

A single operation sometimes suffices, and the cure 
is completed in the space of a few weeks ; but if the 
process should not advance with sufficient rapidity, the 
operation may be repeated once or oftener, interposing 
at least a fortnight between each operation. If the ad- 
hesive process has counteracted his former operation on 
the capsule, he will take care now to effect the perma- 
nent aperture in its centre, and he may use greater li- 
berty than at first in opening the texture of the lens. 

Some have supposed that the fluid cataract is not 
only the most frequent, but the most manageable of the 
congenital cases. Both suppositions are erroneous. It 
is not only the least common, but the fluid,, when extra- 
vasated sometimes excites a hazardous inflammation. In 
these cases, after puncturing the anterior lamella of the 
capsule, and discharging its contents into the anterior 
chamber, it w»ill be prudent to desist for the time, and to 
guard against inflammation : by this operation the case 
will be converted into a capsular cataract. 

Where the lens is nearly or (iviite absorbed, and the 
capsule only is opaque, the surgeon may use the needle 



ELEMENTS OF SURGERY. 369 

Viith more freedom than Iq the lenticular cataract, but in 
other respects he proceeds in the manner above describ- 
ed. If any portion of the lens remain as a small nucleus 
or scale, in the centre of the capsule, his efforts will be 
exclusively directed to detach this portion, by which he 
will fulfil the intention of the operation, that of effecting 
a permanent aperture in the centre of the capsule. 

Mr. Saunders in some cases punctured the sclerotica 
and perforated the capsule from behind : he observes, 
that in this posterior operation the surgeon has more 
power, but that the anterior operation excites less pain 
and inflammation, and inflicts a slighter injury (if any) 
on the vitreous humour; from the facility with which the 
cornea heals I should prefer the anterior operation. 

The number of operations which may be necessary 
to accomplish the cure of a congenital cataract, will de- 
pend much upon the texture of the capsule, and the size 
of the lens. It is frequently cured by a single opera- 
tion ; more frequently it requires two ; often three ; 
sometimes four; but very rarely five. In sixtij patients 
Mr. Saunders, (the author of the operation) succeeded in 
giving sight to fifty-two. In thirteen he operated on sin- 
gle eyes. In forty-seven he operated on both eyes. The 
ages were as follows : five, from two to nine months ; nine, 
from 13 months to two yeais ; four, from two and a half 
to three years ; five, from three and a half to four years ; 
eight, from four to six years. Seven, at seven years; 
eight, from seven to nine ; ten, from nine to fifteen ; and 
four from twenty to twenty-eight. The greatest suc- 
cess attended the operation when performed between the 
ages of 18 months and four years. The age of two 
years is perhaps preferable to any other. It is extreme- 
ly important to operate as early as possible, because, 
the muscles acquire an inveterate habit of rolling the 
eve so that for a long time, no voluntary effort can con- 

vol- I. '^ 



gyO ELEMENTS OF SURGERY. 

trol this irregular motion^ nor direct the eye to objects 
with sufficient precision for the purpose of distinct and 
useful vision. 

I cannot refrain in this place from expressing my high 
sense of the ingenuity of Mr. Saunders, in the contrivance 
of the simple and important operation which has been de- 
scribed. When the advantages of education are consider- 
ed, and the necessity of sight for this purpose, the magni- 
tude of the object will appear very great, and when the 
success of his practice is recollected, (52 cures of 60 pa- 
tients) his skill and judgment cannot be too highly rated. 
Since IMr. Saunders' publication I have met with but one 
case of congenital cataract, (which from all the inquiries 
I can make, I believe to be extremely rare in America, as 
from Scarpa's account it is in Italy) but in that one case 
I succeeded in restoring vision, and my patient, now four 
years old, sees very well. 

Before concluding this subject, I beg leave to suggest 
the propriety in cases of cataract where the pupil is great- 
ly contracted, of using either the belladonna, as directed 
by Mr. Saunders, or the extract of stramonium, which 
operates in the same manner; great difficulty sometimes 
attends the extraction of the lens, owing to the contracted 
state of the pupil, the applications just proposed will 
probably be found to obviate this difficulty, and perhaps 
another, the entangling of the iris on the point of the 
knife, because the dilatation of the pupil, occasioned by 
stramonium and belladonna, is so great, that the iris ac- 
tually resembles a narrow ring at the margin of the cornwi. 

The effect of certain narcotic plants in dilating the 
pupil of the eye, both when externally and internally ad- 
ministered, has been long known, but it is only a few 
years since surgeons have availed themselves of it, in ex- 
amining cataracts, and facilitating their extraction. Mr. 
Wishart, in a paper published in the Edinburgh Med. 
and Surg. Journal, for January 1813; recommends very 



ELEMENTS OF SURGERY. ^Ji 

strongly the hyosciamus, and quotes professor Himly of 
Giittingen, who has made comparative experiments with 
belladonna and hyosciamus, and prefers on his authority, 
as well as from his own observation, the latter article. 
The mode of using it is, to dissolve a dram of the extract 
in an ounce of water, of which solution a few drops are 
to be let fall into the eye. It occasions no pain nor red- 
ness. The effect on the pupil commences in an hour, and 
continues five or six hours. 

There are several advantages which may be gained by 
artificially dilating the pupil. I liave known a lady blind 
except at noon ; her pupil was no larger than a pin's 
head, the use of stramonium enabled her to see tolerably 
in various degrees of light. In examining cataracts, the 
larger the i)upil, the more readily we may ascertain the 
circumstances of the case. It is always in the surgeon's 
power to learn whether the iris be adherent, in which 
case no dilatation of the pupil will be occasioned by the 
narcotic applications. In cases of partial opacity in the 
cornea, the dilatation of the pupil enables the patient to 
see by withdrawing the iris from behind a lucid part of 
the cornea, and thus forming a temporary substitute for 
an artificial pupil : the advantages of a dilated pupil dur- 
ing the operation of extracting a cataract, liave been al- 
ready mentioned ; but an inconvenience has been dreaded 
from the escape of the vitreous humour, in consequence 
of a want of that support which the iris afforded. The 
experiments of Himly quoted by Wishait, appear to 
prove that this fear need not be entertained, and the sur- 
geon may doubtless avail himself safely of the benefits 
which are to be derived from the application of these 
narcotics to the eye. 

Amon**- the consequences of tlie extraction of cataract, 
HYPOPiON and staphyloma are the most formidable, 
happily they are of rare occurrence, I have never seen 
either. Hypopion is a collection of matter in the anterior 



3^^ ELEMENTS OF SUllGEIlY. 

chamber of the eye. The term empyesis signifies a col- 
lection of pus in the posterior chamber, both are conse- 
quences of violent inflammation, and occasionally occur 
after ophthalmia. 

In cases of hypopion the continued use of the reme- 
dies for inflammation seldom fails of producing an ab- 
sorption of the pus; — as this absorption goes on, the 
pus being heavier than the aqueous humour falls to the 
bottom of the anterior chamber of the eye, forming a 
semicircle of a yellow colour, the circumference of which 
is formed by the cornea. It is very seldom necessary to 
puncture the cornea for the evacuation of the pus, active 
purges are to be repeatedly administered, but, if aided 
by the usual depleting remedies they are unsuccessful, a 
puncture must be made. These remarks apply equally to 
hypopion from inflammation of the eye arising from other 
causes. 

The STAPHYLOMA is a tumour projecting through the 
wound of the cornea, formed generally of the iris, but in 
some cases of a transparent membrane, which Wenzel 
calls the capsule of the aqueous humour. When upon 
looking at the eye for the first time, which is generally 
done m six or eight days after the operation, the iris is 
observed protruding through the wound, no attempt should 
be made to replace it; as the opening in the natural cornea 
closes, the iris generally regains its situation. The tumour 
formed by a transparent membrane, is of a very difTerent 
nature. Tlie membrane is probably an adhesion formed 
of coagulating lymph, distended afterwards by an abund- 
ant secretion of aqueous humour; if cut off or destroyed, it 
generally returns again, which would not be the case if it 
were formed of an organized capsule. Wenzel recom- 
mends the case to be left to nature, the eye-lids gradually 
produce by friction and pressure, an absorption of the 
tumour. Staphyloma sometimes results from ulcers of 
the cornea ; in these cases, if it continue obstinate and do 



ELEMENTS OF SURGERY. 3^3 

not subside spontaneously, the lunar caustic must be ap- 
plied. 

Scarpa denominates the staphyloma formed by the iris 
*^ procidentia iridis," which is surely a more proper ap- 
pellation, for it is perfectly distinct from the tumour just 
described, which is often pellucid, but when opaque is of 
a pearly white colour, and easily distinguishable from the 
protruded iris. 

Staphyloma is sometimes occasioned by small-pox — 
in this case the tumour is of a white colour like the 
opaque cornea. In general it ulcerates and occasions in- 
flammation of the eye ; in these cases the tumour may be 
cut off, and should it reappear lunar caustic is to be ap- 
plied. 

The term staphyloma has been vaguely applied to 
many and various tumours of the cornea. It has been 
called total when the whole cornea is morbidly promi- 
nent, and partial when the tumour is confined to a portion 
only. For some very interesting remarks on this sub- 
ject the reader is referred to Wardrop, and Scarpa. 

Since the first edition of the Elements of Surgery, 
some very important improvements have been made in the 
treatment of cataract, which I shall next relate, having 
judged it proper to leave my previous account of extrac- 
tion and couching for the information of those readers 
who may not have access to other works on these sub- 
jects. 

Mr. Saunders's operation of lacerating the capsule and 
destroying the texture of the lens, by means of a double- 
edged needle introduced through the cornea or sclerotica, 
which succeeds so happily in cases of congenital cataract, 
has been found also well adapted to a large number of 
cataracts occurring in advanced life. I have myself em- 
ployed it in a great many cases with complete success, 



374 ELEMENTS OF SURGERY. 

and the facility with which it is performed, together witli 
the little injury which the eye sustains from it, give it 
certainly strong claims to a preference over either couch- 
ing or the former methods of extraction. When I adopted 
this mode of treatment, I commenced a journal of my ope- 
rations and recorded the results of eighteen cases, which 
were published in the second American edition of Coop- 
er's Surgical Dictionary, in 1816, viz : between the S5th 
of April, 1814, and the 25th of October, 1815, I perform- 
ed Mr. Saunders's operation as improved by Mr. (now 
sir William) Adams, in eighteen cases ; at the time of 
the publication alluded to, eight of the patients were 
completely cured ; in two of the cases both eyes were 
cured, in the others only one ; — two of the patients re- 
fused to wait for absorption, and were cured by extrac- 
tion; — in two permanent blindness ensued from violent 
inflammation, and the remaining six were under treat- 
ment. These have since been operated on repeatedly, 
and have all got well, with one exception ; in that case, 
making the third out of eighteen, inflammation destroyed 
the eye. 

I have continued to employ this operation, sometimes 
passing the needle through the cornea and sometimes 
through the sclerotica in a much greater number of cases, 
but of these I have not preserved an entire list : my suc- 
cess, however, has been such as induces me to declare a 
decided opinion that it is far preferable to the usual mode 
of extraction, or to couching. It has succeeded, partially 
or totally, in a great majority of cases, since the publica- 
tion alluded to, but by no means so generally as in sir 
William Adams's practice ; in some it has proved exceed- 
ingly tedious, and my patients, in one or two instances, 
have been twelve months and longer before absorption 
has been completed. The gradual improvement of 
vision; however, satisfies them and eventually success ap- 



ELEMENTS OF SURGERY. QM 

pears as certain as from any other operation. 1 have 
now I believe, operated upon nearly fifty cases, and in 
six of these the eye has been destroyed by inflammation. 
In one of these instances the patient was very old, thccata- 
ract fluid, and immediately on its escaping from the wound- 
ed capsule into the anterior chamber and mixing with the 
aqueous humour, he complained of severe pain— this con- 
tinued and augmented, and although the operation was 
performed with as little violence to the eye as possible, 
suppuration took place. I cannot but ascribe this result 
to some in-itating quality of the fluid lens. In a few other 
cases in which the operation has been very cautiously 
performed, violent inflammation has resulted, but has 
been cured by copious evacuations. 

Sir William Adams has just favoured the world with his 
anxiously expected volume on cataract, and his success in 
treating it seems to exceed any thing which the most san- 
guine hopes could liave anticipated. Of thirty-one cases of 
cataract, at Greenwich hospital, many of which were 
complicated with other diseases of the eye, he complete- 
ly cured twenty-nine ; one only failed, and one was dis- 
missed for irregular conduct.* The testimonials of accu- 
racy in this statement are from the governors of the hos- 
pital, noblemen and gentlemen of great respectability, 
and are entitled to the fullest confidence. The treatment 
of sir William Adams varies in different cases. I shall 
proceed to give an outline of his practice. 

"I shall commence with the description and considera- 
tion of the operation for "solid cataract in children and in 
adults." It is an operation, perhaps, more extensively 

* If this be contrasted with the results of the practice at the Hotel Dieu at 
Paris, it will be found that the improvements are very striking-. In that cele- 
brated institution one hundred and thirteen cases were operated on from 18G6 

to 1810 and of these only forty-three were con>pletely successful, and ten 

partially so. And in the very hospital in which Sir William Adams operated, 
of twenty-four cases In which extraction was performed by the usual method, 
one only succeeded 



giyg ELEMENTS OP SURGERY. 

applicable, and which has proved more generally suc- 
cessful, than any other, either ancient or modern. 

Having secured the eye by makhig a gentle pressure 
with the concave speculum, introduced under the upper 
eye-lid, I pass the two-edged needle through the sclero- 
tic coat, about a line behind the iris, with the flat surface 
parallel to that membrane ; it is then carried cautiously 
through the posterior chamber, without in the slightest 
degree interfering with the cataract or its capsule. When 
the point has reached the temporal margin of the pupil, I 
direct it into the anterior chamber, and carry it on as far 
as the nasal margin of the pupil, in a line with the trans- 
verse diameter of the chrystalline lens. I then turn the 
edge backwards, and with one stroke of the instrument, cut 
in halves both the capsule and cataract. By repeated cuts 
in different directions, the opaque lens and its capsule, 
are divided in many pieces, and at the same time I take 
particular care, to detach as much of the capsule as pos- 
sible from its ciliary connexion. As soon as this is ac- 
complished, I turn the instrument in the same direction 
as when it entered the eye, and, with its flat surface, 
bring forward into the anterior chamber, as many of the 
fragments as I am able : by these means, the upper part 
of the pupil is frequently left perfectly free from opacity. 
By cutting in pieces the capsule and lens at the same 
time, not only is capsular cataract generally prevented, 
but the capsule is also much more easily divided into mi- 
nute portions, than when its contents have been previously 
removed. 

The needle which I employ in this operation, is eight 
tenths of an inch long, the thirtieth part of an inch broad, 
and has a slight degree of convexity through its whole 
blade, in order to give it sufficient strength to penetrate 
the coats of the eye without bending. It is spear-pointed, 
with both edges made as sharp as possible, to the extent 
of four- tenths of an inch. Above the cutting part, it gra- 



ELEMENTS OF SURGERY. WM 

dually thickens, so as to prevent the escape of the vitre- 
ous humour.* 

This instrument, it is apparent, is well calculated to 
cut in pieces with facility, any cataract whose nucleus is 
not too solid to admit of division, and from the peculiar 
manner in which it is employed, (by making the vitreous 
humour and the attachment of the capsule to the ciliary 
processes, a counter-resistance to the cataract, while acted 
upon with its edge turned backwards,) is capable of di- 
viding the nuclei of lenses of a greater degree of solidity, 
than could be effected by any other instrument hitherto 
used for the same purpose. Most of these instruments 
are sharpened, a short way only from their point, and any 
attempt to divide with them a lens of any considerable 
degree of solidity, would, instead of accomplishing the di- 
vision, detach the lens from the ciliary processes, when, 
according to the usual practice, no alternative remains but 
either to depress the lens in the vitreous humour, or to 
place it in the anterior chamber for solution and absorp- 
tion, whole and undivided, which latter practice can 
never be done with safety, when its nucleus does not admit 
of division. 

The first step of this operation consists in carrying the 
needle through the coats of the eye, which, from its spear 
point and sharp edges, can be effected with a very slight 
degree of force, as it penetrates the dense sclerotic with 
as much facility as a lancet, while, from its very small 
size, it inflicts as little injury upon the organ as it is pos- 
sible for any instrument to do. There is reason to be- 
lieve, that the degree of force which is necessary to be 
used, in effecting this step with a needle whose blade is 
round, instead of being flat, is one source of the inflam- 
mation which immediately succeed^ to the operation, 

* An en^'avingis unnecessary from its resemblance to Saunders' needle. 
VOL. T. 49 



gyg ELEMENTS OF SUltGERY. 

while the wound inflicted upon the coats of the eye, par- 
taking more of a contused than an incised wound, is not 
only another source of irritation and inflammation, hut 
also prevents its healing kindly, which evidently cannot 
be the case when my sharp-edged needle is employed. 
It has, however, been stated, that the eye sustains less 
injury from the use of a blunt than of a sharp-cutting in- 
strument, but this opinion I conceive to be entirely erro- 
neous ', where any part is to be divided, it can obviously 
be done with less injury and violence, the sharper the in- 
strument employed, provided it is used with skill and 
judgment. If this argument applies to operations in ge- 
neral, how much more forcibly may it be urged, in regard 
to those on the eye ; wlien any considerable degree of 
force is there employed, either from the nature of the ope- 
ration itself, or from the instrument with which it is ex- 
ecuted, a degree of inflammation is produced, which too 
often baffles the utmost skill of the operator. On this ac- 
couut, it is observable, that the most experienced oculists 
are the most particular in their instructions relative to 
the form and condition of their instruments, all agreeing, 
that the favourable termination of the section of the cor- 
nea, greatly depends upon the good condition of the 
knife ; and surely, if it is the principle of an operation 
to divide the cataract, that object can be more expe- 
ditiously accomplished, and with less violence to the eye, 
with a sharp-cutting needle, than with a blunt one, in 
which latter case, the cataract is torn, rather than cut; so 
many movements of the needle are also required, as not 
only to prolong the sujfferings of the patient, but the con- 
tinued action of the instrument upon that part of the coats 
of the eye in which it is inserted, necessarily excites in- 
flammation, and hazards the total failure of the ope- 
ration. 

From the facility with which my needle penetrates the 
Coats of the eye, the operator (particularly if he lias been 



ELEMENTS OP SURGERY. wa 

m the habit of employing needles with round blades) 
should be careful not to use much pressure, and should 
make the puncture at a sufficient distance behind the iris, 
and parallel with its plane surface, otherwise the point 
may either pass through that membrane before it reaches 
the edge of the pupil, or be carried too far into the eye 
towards the nose. In either case, however, no f?erious 
mischief is to be apprehended, and these accidents can 
only occur to a very inexperienced and unsteady operator, 
who would probably do much more mischief to the eye, 
by any other mode of operating ; the eye being rendered 
immoveable by the speculum, and the pupil previously 
dilated by the belladonna, the iris is the only part at all 
likely to be injured in this step of the operation, unless 
indeed the instrument be broken in penetrating the coats 
of the eye, an accident which, when the operation is per- 
formed, agreeably to the description of it given at length 
in my work on Diseases of the Eye, can only happen from 
iinskilfulness. 

The second step of the operation consists in dividing 
both capsule and lens, with the same stroke of the knife. 
This may be always accomplished, when the vitreous 
humour is in a healthy state, in young, and frequently in 
old persons, by turning the edge of the knife backwards, 
in the manner directed, provided the usual degree of firm- 
ness, in the attachment of the capsule to the ciliary pro- 
cesses, exists. In those cases, however, where the nu- 
cleus of the lens is too solid to admit of division, if an at- 
tempt is made immediately to di\dde the lens, it will be 
entirely separated from its natural adhesions, when, 
should the vitreous humour be partly or wholly disorga- 
nized, the cataract will immediately become spontaneously 
depressed, when it cannot be extracted, without hazard- 
ing a very dangerous escape of the vitreous fluid. This 
\s the only accident to which the second step of the ope- 
ration is liable; when properly conducted : as, if the iris 



3go ELEMENTS OF SURGERY. 

be wounded with the point of the needle, it must, as in 
the first, at all times be the fault of the operator. Should 
he not have had sufficient experience to enable him to as- 
certain with precision, the nature of the cataract by pre- 
vious examination, he may certainly fall into the error, of 
attempting to divide a lens, which is too solid to admit of 
such division, when, should the vitreous humour prove to 
be in a disorganized state, he necessarily subjects the pa- 
tient, to the dangers already detailed, from the depression 
of a solid lens, in a fluid vitreous humour. As this know- 
ledge can only be acquired by practice, and observation, 
the young operator, in all doubtful cases, should proceed 
with caution ; and, instead of attempting to cut the cap- 
sule, and cataract in halves, with one stroke of the in- 
strument, it will be prudent in him, to act at the first only 
with its point ; by this means, he will be enabled, to as- 
certain the consistence of the opaque lens, which will di- 
rect him how to proceed, in the prosecution of this, the 
most important step of the operation. 

Having effected the division of the nucleus of the ca- 
taract, the operator is then to remove the divided portions 
with the point of the needle, through the aperture of the 
pupil, into the anterior chamber, which constitutes the 
third, and last step of the operation. 

When the consistence of the cataract is tolerably firm, 
there is no difficulty in placing a part, or even the whole 
of the divided lens in the anterior chamber, should it be 
adviseable so to do, such is the dilated state of the pupil; 
no impediment is presented to the accomplishing that ob- 
ject ; but when, as sometimes happens, the lens is very 
soft, and of a jelly-like consistence, the flat part of the 
needle, passes through it, with as much facility, as if it 
were turned edgeways, in which case, after freely divid- 
ing the capsule, as well as the lens, it will be better, to 
Avoid irritating the coats of the eye considerably, by re- 
peated attempts to pass the portions of cataract tluough 



ELE>rE>nrs of surgery. 38jI 

tJie pupil, which might probably produce iuflammation, 
but rather to let it remain in situ, (taking care, however, 
to prevent its pressing too much against the posterior part 
of the iris,) where it will in a few weeks become lessened 
in quantity, and acquire a consistence which admits of its 
being removed with great readiness into the anterior 
chamber, if it be necessary to repeat the operation. In 
this stage, also, the iris may be wounded with the point 
of the needle, from a want of dexterity in the operator, 
but otherwise that accident will never happen, as, from 
the dilated state of the pupil, its circular margin is suf- 
ficiently out of the way of the needle, when the operatiou 
is skilfully performed. 

If the capsule be partially, and not completely cut in 
pieces, during the division of the lens, after placing the 
fragments of that body in the anterior chamber, the cap- 
sule should be lacerated to the full extent of the area of 
the pupil. In doing this, the iris is alone the part sub- 
jected to injury; whatever injury the ciliary processes, or 
vitreous humour, have sustained during the posterior ope- 
ration, (as the introduction of the needle behind the iris 
has been called,) being of no moment whatever, the uses 
of the ciliary processes having ceased, as soon as the 
chrystalline lens is removed ; and it is evident, from the 
very little irritation generally excited in the eye by the 
operation for capsular cataract, that no inflammation is to 
be apprehended from the laceration of these processes by 
the needle ; experience in the operation for couching, 
(but especially the circumstance of the patient's vision 
not being perceptibly impaired, when the vitreous hu- 
mour is in part or wholly disorganized,) renders it equally 
certain, that no injury is occasioned by the needle hav- 
ing lacerated the vitreous tunic. 

The next operation to be considered is that for " cap- 
sular and adherent capsular cataract." The needle used 
in this operation, although slightly curved, is much less 



^gg ELEMENTS OF SURGEUY. 

bent at its point, than that recommended by Professor 
Scarpa, on which account the surgeon can direct the point 
of it with greater ease and precision, for the purpose of 
separating minute portions of capsule, when adherent to 
the iris. In this operation the capsule should be lacerat. 
ed very freely, as much as its consistence will possibly 
admit of*, but when that membrane is too thickened to 
enable the operator to accomplish this object, he must 
then detach it, from its ciliary connexion, except at one 
small part, as I have already described, and afterwards 
place it out of the axis of vision. In effecting these 
steps, there is less likelihood of wounding the iris even 
than in the operation for children and young persons, 
from the point of the needle, which is introduced at the 
same distance bebind the iris, being somewhat curved, 
and directed towards tlie bottom of the eye, the pupil be- 
ing dilated by the belladonna. 

When the capsule adheres to the iris, constituting 
« adherent capsular cataract," the operator must pro- 
ceed more cautiously, otherwise, in liberating the adhe- 
sions between the cataract and the iris, the latter mem- 
brane may be injured, and thereby give rise to severe 
inflammation ; or, should the adhesions be very firm and 
extensive, a forcible attempt at separation would be like- 
ly to detach the iris from the ciliary ligament, and conse- 
quently occasion an obliteration of the natural pupil. In 
this, as in the operation for capsular cataract without ad- 
hesions, care must be taken not entirely to detach the 
capsule from the ciliary processes, as it would float about 
in the vitreous humour, and probably obstruct the pupil ; 
but, on the other hand, if not sufficiently detached, it will 
be likely, particularly if much thickened, to rise again 
into its former situation. Should these accidents occur, 
the evils resulting from them may be avoided ; the float- 
ing portions may be extracted through a small puncture 
in the cornea, and if the capsule should rise, the operator 



ELEMENTS OP SURGERY. 383 

iuay again introduce the needle through the same punc- 
ture in the eye, and detach it still further ; or, if the re- 
turn sliould not take place for some time after the opera- 
lion, it may be again repeated, and the further detachment 
effected, as may be necessary. 

Ill " adherent lenticular cataract y^^ when the pupil is 
not too much contracted, provided the nucleus of the lens 
is sufficiently soft to admit of division, I employ the same 
two-edged needle as in operating for the solid cataract in 
young persons. Part of the fragments should then be 
carried through the pupil with the point of the needle 
into thQ anterior chamber for solution and absorption. 
In this case, great caution is necessary on the part of the 
operator, both from the small size of the pupil, and from 
the extensive adhesion of the capsule of the lens to the 
iris, affording a much smaller area for the action of the 
needle, and thereby rendering the iris more liable to be 
cut or punctured with the point of the instrument, while 
dividing the lens ; in effecting this division, unless the sur- 
geon proceed with similar caution, the iris is put so much 
upon the stretch as either to hazard its partial detachment 
from the ciliary' ligament, or to produce a considerable 
degree of inflammation. By proper care and delicacy in 
the use of the needle, these dangers may, however, be 
wholly avoided, and are to be apprehended only, when 
an injudicious degree of force is employed with the in- 
strument. If the pupil be too much contracted for the 
purposes of vision, the surgeon, instead of using the 
two-edged needle to cut up the cataract, should, at the 
first, proceed to the division of the iris, in order to form 
an artificial pupil, in a manner which will presently, be 
minutely described. 

When the lens is hard and solid, and the pupil suffi- 
ciently large to admit of its free passage, I at once carry 
the lens forwards into the anterior chamber, with the two- 
edged needle, ready for extraction, but more commonly 



38^ ELEMENTS OF SURGERY. 

the pupil requires enlargement before this can be eifect- 
ed. The iris scalpel, should in this case be employed at 
first, with which the iris should be divided transversely 
full two-thirds of its extent, and the lens afterwards car- 
ried through this new opening, into the anterior cham- 
ber, with the point of the same instrument. Should the 
lens be soft, and even transparent, both lens and capsule 
ought to be cut through and divided, the capsule being 
always opaque, which would intercept the rays of light; 
equally as if the lens were in the same state. 

In introducing the iris scalpel at the usual distance be- 
hind the iris, its edge should at the first be turned back- 
wards instead of upwards or downwards ; by that means, 
the stretching of the aperture in the coats of the eye, which 
ensues from subsequently turning its edge backwards, 
(as is recommended in the o[)eratiou for solid cataract in 
young persons,) and also the escape of a portion of the 
■vitreous humour, when partially or wholly disorganized, 
will be prevented. It is of great importance that this 
escape should not take place in this particular species of 
case, for the coats of the eye being thereby rendered flac- 
cid, a sufficient resistance to the action of the knife is not 
afforded in dividing the iris ; whereas, if the operator en- 
deavours to accomplish his object by increasing the degree 
of pressure upon the instrument, he will detach that mem- 
brane from its ciliary ligament, instead of dividing it. It 
is necessary not only to divide the iris, but either to de- 
tach, or divide the capsule of the lens, to the full extent 
of the opening of the iris, otherwise its radiated fibres 
cannot retract the edges of the divided membrane suffi. 
cieutly distant from each other, to prevent their reunion 
by the first intention, unless indeed some portions of the 
fragments of the divided lens are interposed between 
them. 

For the purpose of dividing the iris, I introduce the 
point of the instrument, through the coats of the eye, 



ELEMENTS OF SURGERY. J}85 

about a line behind that membrane. The point is next 
brought forward through the iris, somewhat more than a 
line from its temporal ciliary attachment, and cautiously 
carried through the anterior chamber, until it nearly 
reaches the inner edge of that membrane, when it should 
be drawni nearly out of the eye, making gentle pressure 
with the curved part of the cutting edge of the instrument, 
against the iris in a line with its transverse diameter. If, 
in the first attempt, the division of the fibres of the iris is 
not sufficiently extensive, the point of the knife is to be 
again carried forward, and similarly withdrawn, until the 
incision is of a proper length. I take care, however, 
very freely at the same time to cut the cataract in pieces. 
Some of these pieces I bring into the anterior chamber, 
and leave the remaining portions in the newly-formed 
opening of the iris. These act as a plug in preventing its 
reunion by the first intention, and assist the radiated 
fibres, in keeping the pupil more extensively open ; by 
the time these fragments are dissolved, the iris has lost 
all disposition, or indeed power, of again contracting, its 
divided edges having by that time become callous, and be- 
ing drawn considerably apart by the permanent contrac- 
tion of the radiated fibres." (Adams.) 

In reviewing the innovations introduced within a few 
years in the treatment of cataract, every intelligent sur- 
geon will perceive, that they embrace modifications of every 
mode of operating hitherto employed, and are to be re- 
garded more in the light of improvements than inventions, 
nor is this conclusion derogatory to the characters of 
those by whom these new modes of operating have been 
mirodvLced— Since his merit is surely greatest, whose 
practice succeeds best. Mr. Hey has a sentence which 
I shall here transcribe, as proving that before Mr. 
Saunders or sir William Adams were knoAvn in the 

VOL. I. ^^ 



ggQ ELEMENTS OF SURGERY. 

medical profession, he had accidentally performed their 
operations. 

<^ Though I do not think it advisable to persist in 
pressing an entire cataract into the anterior chamber, 
when the advance of the cataract causes a large dilatation 
of the pupil ; yet after the needle has wounded the cap- 
sule, a firm cataract, or at least its nucleus, will sometimes 
slip through the pupil without the design of the operator. 
This has been considered by some authors, as a disagreea- 
ble circumstance, and has been ranked amongst the ob- 
jections to the operation of. couching. On the contrary, 
it ought to be considered as a favourable event^ since the 
cataract always dissolves in the aqueous humour, and 
finally disappears icithout any injury to the eye. This, at 
least, has been the event in every case of the kind which 
I have seen. I have six or seven times seen the whole 
opaque nucleus fall into the anterior chamber of the eye, 
and very frequently small opaque portions. Indeed, if 
the cataract could, in all cases, be brought into the ante- 
rior chamber of the eye, without injury to the iris, it 
would be the best method of performing the operation. 
But this is not usually practicable ; the softness, as well 
as the bulk of the cataract presenting an obstacle to this 
process.'' 

It is strange that Mr. Hey should state, that when the 
nucleus of a cataract accidentally escapes into the aqueous 
humour it is a favourable circumstance, and should yet 
never have done by design what succeeded so well by 
accident. 

Sir William Adams's new mode of extraction I have 
too recently been acquainted with to decide upon it. I 
think it well entitled to trial, and shall try it impartially. 

One remark I shall make in concluding this article, 
which is, that it is impossible to anticipate the degree of 
ioflammation likely to result from any operation on the 



ELEMENTS OF SURGERY. 387 

^yfe. In some cases when merely punctured, it inflames 
very violently, and in others, where the operation is diffi- 
cult and protracted, scarcely any inflammation results. 
This remark must not be construed into an apology for 
violence, or for too much effort to destroy tlie texture of 
the lens, for I believe that the surgeon who treats the 
organ most tenderly will be most sure of success. 

My own practice at present is to destroy as much as 
possible the texture of the lens and capsule in the manner 
described by sir William Adams, and with the same in- 
struments, and to push the fragments as much as possible 
into the anterior cliamber for solution and absorption. 
When the nucleus remains unabsorbed and very hard, I 
propose in future to extract it. I have in two cases found 
long continued inflammation to result from leaving a large 
portion of hard cataract in the anterior chamber ; these 
portions are diminishing however daily, and I trust will 
be ultimately removed. Some of my patients with very 
tough membranous cataracts, have as yet, derived no bene- 
fit from the operation, and are still under treatment. I 
have a gouty patient thus circumstanced, whose eye occa- 
sionally inflames severely during his gouty paroxysms. 



388 KLEMEMS OF SURGEliV. 

CHAPTER LX. 

Extirpation of the Eye, 

This operation, terrible in its nature, is extremely sim- 
pie. The diseases which render it necessary are not 
very accurately defined. In general it is performed for 
the removal of a disorganization which commences, and 
terminates in a fungous tumour : in some cases this af- 
fection begins without pain, but commonly it is preceded 
by head-ache, and itching and watering of the eye. It is 
in some cases truly cancerous, but in others, probably, 
has no cancerous tendency. It occurs at all ages, but 
oftenest in young persons. More than one-third of De- 
sault's patients were under twelve years of age. As the 
disease advances great pain is perceived — sight is lost — 
the cornea inflames, ulcerates, and bursts — a fungous red 
tumour projects through it, discharging a purulent sanie«, 
fetid and acrid — the size of the tumour becomes very 
great. I extirpated a fungous tumour of this nature from 
the socket of a boy's eye, resembling, except in colour, 
a cauliflower, its size and appearance are represented in 
the annexed plate — no return of the disease took place. 
The plate affords a tolerable idea of the general form of 
this dreadful malady. 

Tlie operation is to be performed, when practicable, 
by separating the lid, from the ball of the eye with a 
scalpel : but in many cases this is impracticable, and all 
that can be done is to save as much of the upper lid as 
possible, provided it be sound. A straight bistoury of 
sufficient strength is to be passed as quickly as possible 
round the basis of the tumour, the surgeon making it 
rcTolve upon its point in such a manner as to keep the 



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% 



:>\ 



> 






/ 



V 



Ccvrcmomii of t/tel^ye 



.I.S./for.-rx </<' '^' ^ <'"'/' 



ELEMENTS OF SURGERY. 3S9 

edge close to the bony orbit. Having seen Mr. Dubois 
at Paris perform the operation in this simple manner, I 
have imitated his example, and in a very short time the 
operation is completed. Any portions of the tumour 
which remain may be afterwards removed, but as the 
hemorrhagy is always very profuse, whatever cutting is 
done, should be done quickly. The orbit is to be filled 
with lint, and the bleeding soon ceases. The antiphlo- 
gistic regimen should be adhered to for a few days. 

Sometimes the fungus returns, and although often 
destroyed, as frequently springs up. In these cases the 
event is fatal. But as death is inevitable if the disease 
be not extirpated, the attempt ought always to be made. 
I have four times performed the operation, and three of 
the four patients remain quite free from disease. The 
fourth was attended witli disease of the absorbent glands, 
and terminated fatally, though life appeared to be pro- 
longed by the operation. 

TAPPING THE EYE. 

Dropsy of the eye, or hydrophthalmy, sometimes ren- 
ders it necessary to evacuate the aqueous humour, accu- 
mulated in too great quantity. Scarpa states that in 
the cases of dropsy of the eye which he has dissected, 
the vitreous humour has been in a morbid state of fluidity, 
and he was unable to distinguish it from the aqueous 
humour. The proper internal remedies having been 
in vain administered, if the eye-ball continue to aug- 
ment in volume, and protrude from the socket, it be- 
comes necessary to open the eye by a surgical operation. 
Nuck used to puncture the centre of the cornea with a 
small trochar; other writers recommend the puncture 
to be made through the sclerotica. Scarpa advises a 
small circular incision to be made in the upper part or 



390 ELEMENTS OP SURGERY. 

centre of the cornea, as the best mode of evacuating the 
eye. In several cases I have punctured the cornea by 
inserting the point of a sharp cataract knife through it, 
the evacuation of the aqueous humour although not sud- 
den, was amply sufficient, but if necessary it is very easy 
to turn the knife a little, so as to make the incision some- 
what circular, whereby the fluid will more readily es- 
cape. 

Dr. Physick from an idea that gutta serena is in some 
cases occasioned by pressure upon the retina and optic 
nerve from an over secretion of aqueous humour, has 
punctured the eye with a view to relieve this affection. 
In some instances the operation has been evidently ad- 
vantageous — in others no benefit whatever has resulted. 
I have suggested this because I shall not enter into the 
history of tliis paralytic affection of the eye, as many ex- 
cellent histories of it are in the hands of every medical 
man. Richter, Scarpa, and Ware are among the best 
writers on the subject, and to them I refer, only suggest- 
ing that in very obstinate cases where other remedies have 
failed, tapping may be tried, as it has been sometimes 
useful, and the repeated application of blisters directly 
over the eye-lids, are also occasionally beneficial. 



Plate XIII. 




"LATE XW. 




ELEMENTS OF SURGERY. gQi 



EXPLANATION OF THE PLATER. 

Fig. 1. Represents the most usual form of Pterygium or 
Unguis. 

2. The appearance of an eye, after the excision of 
that portion of the palpebra, from which the cilia 
project ; an operation performed for the cure of 
Entropium or Trichiasis. 

3. Curved scissors used in various operations on the 
eye. 

4. Forceps. 

5. Saunders' couching needle. 

6. Scarpa's couching needle. 

7. Hey's couching needle. 

8. Represents the section made in the cornea in the 
operation of extracting a cataract. 

9. An artificial pupil, near the external margin of 
the iris. 

10. The place of introducing the cornea knife and 
the mode of passing it through the anterior cham- 
ber of the eye. 

11. This figure represents an accident which some- 
times happens in the operation of Extraction, 
the floating of the iris before the blade of the 
knife. 

13. The forceps contrived by Dr. Physick, with a 
circular punch on the extremities of the blades. 

13. A small hook useful in the operation of Extrac- 
tion. 

14-. Wenzel's knife for incising the cornea. 

15. Curette and needle. 

16. Wenzel's forceps. 

17. The nail-headed style used in fistula lachry- 
malis, 



§92 ELEAIENTS OF SURGERY, 

CHAPTER LXI. 

Of Polypus. 

A POLYPUS is a fleshy excrescence, of various density 
and colour, originating from the lining membrane of a 
canal or cavity, as the nose, vagina, rectum, &c. 

The nostrils are the most frequent situation of this com- 
plaint. It commences as a small pendulous tumour, void 
of pain, accompanied with watering of the eyes, sneezing, 
and the usual symptoms of catarrh. The colour of these 
tumours is g6nei*ally a pale red. They commonly com- 
mence from the ossa spongiosa ; but occasionally from all 
the parts concerned in forming the cavity of the nostril. 
They produce at first no other efi'ects than have been 
noticed, but as they enlarge, the detluxion from the 
eyes increases, sneezing is frequent, and the tone of 
voice is much altered. The weather has a great in- 
fluence on the patient. In dry weather the tumour ap- 
pears to diminish, and it increases in damp and coljl 
weather — augmenting gradually in size, it at length ob- 
stmcts the passage of air through the nostril and in 
this stage produces a very unpleasant nasal tone of 
voice. The polypus assumes gradually the shape of the 
cavity of the nose, being formed in it as in a mould. It 
becomes visible at the anterior nostril and at the fauces 
behind, where it maybe seen situated over the soft palate, 
and sometimes hanging down behind the uvula. In this 
state great inconvenience is experienced — the eyes are 
constantly suffused with tears, from the obstruction to the 
ductus ad nasum. In some instances, ulceration takes 
place, and a fetid matter is discharged, attended with 
great inflammation and severe pain. In some cases, how- 
ever, it is remarlsable that the tumour acquires a great 



ELEMENTS OF SURGERY. ^9^ 

size and the patient suflfers no pain. From the nose be- 
ing stopped patients generally sleep with the mouth open, 
and inconvenience is sustained from the dryness of the 
mouth and throat. Hearing is often injured, probably 
from pressure against the Eustachian tube. In swallow- 
ing, some difficulty is experienced from the weight of the 
tumour which presses against the velum pendulum palati. 
The appearance of ihe face becomes changed from one 
nostril being wider than the other, the root of the nose ap- 
pears swelled, and violent head- aches come on — the 
bones eventually become carious and ulcerated — a foul 
fetid sanies mixed with blood is discharged — hemorrhage 
sometimes ensues — the teeth fjiU out and a fungus shoots 
through the sockets. These symptoms in some cases in- 
crease and exhaust the patient's strength; — frequent 
bleedings and an incessant discharge of matter take place, 
and during the last stage of the disease, stupor and coma 
come on, and eventually death. — Such are sometimes the 
dreadful effects of a disease at first trifling, and to all ap- 
pearance of very little consequence. 

The causes of this complaint are not well understood. 
Some have supposed picking the nose, or violently blow- 
ing the nose to have produced it, but for this there is no 
foundation. 

Several species of nasal polypi are described by au- 
thors, one of which is said to be of a malignant nature, 
disposed to end in cancer. This, however, I believe is 
extremely rare ; the most common are a fleshy, red vas- 
cular polypus, and a pale tough, firm polypus, neither of 
which is of a cancerous nature. 

TREATMENT. 

The cure of polypi consists in extracting or destroying 
them with caustic. 
VOL. I. 51 



3^4) ELEMENTS OF SURGERY. 

The extraction may be performed by forceps, or by 
passing a ligature round the base of the tumour in such 
a manner as to destroy the circulation, after which the 
polypus soon falls off. The application of a ligature is 
to be preferred in cases where the pedicle by which it 
hangs is very small, or in cases where the patient is too 
feeble to bear the loss of blood which is apt to follow the 
nse of the forceps. The mode of applying the ligature 
must vary in different cases. Sometimes all that is ne- 
cessary is to pull the polypus forward with a hook and 
pass a silver wire over it — or a waxed ligature may be 
formed into a noose and passed round the base of the tu- 
mour in the same way. When the wire is to be used 
a double canula is generally the best instrument for fix- 
ing it — it must be drawn very tight, and in a few days 
the polypus will fall off. It is of great importance to 
watch when the polypus becomes loose, as it has occa- 
sionally separated in the night time and endangered suf- 
focation by falling over the glottis. A case of this com- 
plaint occurred several years ago in which Dr. Physick 
practised a new mode of extraction that will probably 
be found useful in many other instances. A gentleman 
having suffered many unsuccessful attempts for the re- 
moval of his polypus, came to Philadelphia and consult- 
ed Dr. Physick — he found a large tumour projecting be- 
hind tlie soft palate as low as the extremity of the uvula, 
and filling completely the posterior nares and cavity of 
the nose, after vain attempts to extract it in the usual 
manner with ligature and forceps, a piece of tape was 
made stiff by passing silver wire through it, and this was 
fixed on the projecting part of the tumour by a firm 
knot — the tape was now pulled forcibly and with it 
Game away the polypus, which was of prodigious size. 

In using the forceps they must be applied as near the 
root of the polypus as possible. Hemorrhage generally 



ELEMENTS OF SURGERY. 395 

attends the operation but it is not often alarming — cold 
water or brandy injected into the nose generally checks 
it. If not, a plug of lint may be introduced into the nos- 
trils so as to press on the part whence the blood issues. 
If necessary the posterior nostrils may be stopped up 
by passing a double catgut through the nose into the 
mouth and by means of this a roll of lint is readily in- 
troduced into the posterior nares which invariably suc- 
ceeds in putting a stop to the hemorrhage. 

The application of caustic is often requisite to prevent 
the growth of the tumour after the greater part of it lias 
been removed. This is in general easily effected by 
means of a bougie, or a roll of waxed linen in which is 
included a piece of caustic alkali. 

Tlie application may be repeated daily until the tu- 
mour no longer grows up. 



395 KLEMENTS OF SURGERY. 

CHAPTER LXII. 

Of Ranula. 

This consists in a tumour under the tongue containing 
a glairy fluid, resembling the white of an egg. It is 
supposed to proceed from an obstruction in the salivary 
duct. The tumour is generally on one side of the frse- 
num linguae, and varies greatly in size, sometimes ex- 
tending to the very point of the tongue, and elevating it 
considerably.* The tumour sometimes contains instead 
of the viscid fluid which has been mentioned, a purulent 
matter, and, sometimes, a calculous concretion. When 
uninflamed the disease gives no pain, but from its bulk 
is more or less inconvenient ; when it inflames considera- 
ble pain is experienced. 

TREATMENT. 

The remedy for ranula, that is, for a tumour actually 
formed by a dilatation of the salivary duct, consists if 
possible in dilating the duct by means of a probe, as 
recommended by Desault; but it is not often in our 
power to effect this, and other measures become neces- 
sary. 

The extirpation of the tumour is difficult and danger- 
ous on account of the large blood-vessels in the vicinity. 
The British surgeons are in the habit of laying open the 
cavity of the tumour, by a free incision, after which they 
apply caustic to its surface. This plan does not always 
effect a cure, and is uiinecessarily severe ; a simpler and 

* I have never seen these tumours very large, but when suppuration takes 
place in them, large abscesses have been formed, and as much as a pint of mat- 
ter has been discharged from under the tongue. 



ELEMENTS OF SURGERY, ^97 

easier method should therefore have the preference. In 
a majority of cases the disease may be cured, as recom- 
mended by Dr. Physick, by passing a seton through the 
cavity of the sac ; a common curved needle armed with a 
ligature can readily be passed through the tumour, the 
needle being cut off, the string is suffered to remain in 
tlic cavity of the tumour where it excites inflammation 
and suppuration, after whicii a fistulous orifice is estab- 
lished through which the saliva afterwards flows, and 
this is soon followed by a complete obliteration of the 
cavity. I have known this simple remedy successful in 
a great number of cases, and I believe it will be found 
to fail in very few. 

If calculous concretions are found in the sac they must 
be removed, and the caustic if necessary can be applied 
for the purpose of destroying the sac. I have met with 
a very difficult case of ranula attended with a large cal- 
culous concretion, which occasioned an abscess and sali- 
vary fistula in the neck. In this case the calculus en- 
larged, and was found in close contact with the carotid 
artery and compressing the oesophagus and trachea. I 
succeeded in rescuing my patient from his dangerous con- 
dition by injecting into the cavity containing the calculus, 
diluted sulphuric acid, which softened the stone and 
enabled me to extract it with forceps through an in- 
cision made cautiously down to the stone. The aper- 
ture of the submaxillary duct being enlarged by probes 
and bougies, the external wound healed up in a short 
space of time. 

It has occasionally happened that a small calculus in 
the duct produces the obstruction, in which case all that 
is necessary is to remove it, after which the tumour will 
subside. 

Mr. B. Bell relates such a case which terminated in 
ulceration of the cavity. The ulcer could not be healed 
until the calcnlus w as removed. 



398 ELEMENTS OF ^RGERY. 

CHAPTER LXin. 

Of Salivary Fistulce. 

In ccnsequeiice of wounds of the cheek or of ulcers, 
the duct of the parotid gland is sometimes opened and 
discharges its contents externally. When the patient is 
eating, the saliva instead of being poured into the mouth, 
flows out upon the cheek. Whether the loss of this fluid 
occasions any eftect upon the digestive organs or not, the 
complaint is found extremely inconvenient, two ounces of 
saliva are said to have flowed out of such a fistula dur- 
ing a single meal. 

In case of a recent wound which opens the parotid 
duct, great care should be taken to unite very accurately 
the sides of the wound externally; in this way the proba- 
bility is, that the duct will eitlier reunite or form a fistu- 
lous orifice internally, either of which occurrences will 
prevent the formation of an external fistula. 

When the fistula has existed for a considerable time, 
and attempts have been made by pressure, caustic ap- 
plications, and other means, to heal up the ulcer without 
eflFect, more difficulty is to be anticipated. In these casesj 
it is necessary in the first place to establish an opening 
into the mouth, and afterwards to heal up the external 
orifice. 

Mr. Charles Bell directs the following measures, which 
I believe were contrived by the celebrated Dr. Monro : 
" Our first attempt will be to pass a small silver probe 
from the mouth into the natural opening of the duct, and 
enlarge it, if it shall be found contracted ; then to sub- 
stitute a small tube, which being introduced from the 
mouth shall also pass some way into that part of the 



Elements of surgery. 399 

duct which discharges the saliva. Lastly, while the tube 
is retained in its place, the outward lips of the wound are 
to be made raw, brought together and healed. 

" But the circumstances of the case may be such, that 
it will be better to make a new duct, from the fistulous 
opening into the mouth. To do this we must push a 
straight needle, obliquely from the bottom of the fistula 
into the mouth, and draw through a small seton, which 
is to be worn until the passage is callous. Then either 
with or without introducing the tube, we have to endea- 
vour to unite the edges of the outward opening." 

Desault made use of the seton in the treatment of 
salivary fistulae, but instead of introducing it in the usual 
manner, he complicated his operation by using a trochar 
instead of a needle. His mode of cure which differs in 
several particulars from the one just described, appears 
to have no advantages over it. 

The patient during the cure, should as much as possi- 
ble avoid speaking, and should be nourished principally 
upon spoon victuals. 



40Qi ELEMENTS OF SURGERY. 

CHAPTER LXIV. 

Of Mscess of the Antrum Maxillare. 

This cavity is sometimes the seat of inflammation and 
suppuration. The complaint commences like a fit of 
tooth- ache, a severe darting pain extending through the 
jaw, without any external tumefaction : afterwards sup- 
puration takes place; the pus flows into the nostril of 
the affected side, especially when the head is inclined 
in such a position as to favour its escape. The disease 
even after suppuration is established is not always easily 
known, for the mucus of the nostril often resembles pus, 
and the pus is mistaken for the common secretion of the 
nostril. In some cases the affection subsides after sup- 
puration takes place, but more generally it continues, and 
occasions caries of the bone. The absorbents remove 
portions of bone, and make outlets for the pus in different 
places. In some cases the sockets of the molar teeth are 
absorbed, the teeth loosened, and the pus discharged 
through the openings thus formed into the mouth. 

The cause of the disease is often a caries of the upper 
molar teeth and consequent inflammation of the sockets, 
extending gradually to the antrum. 

The treatment of the abscess is to be commenced by 
extracting any carious teeth which may exist in its vici- 
nity ; this removes in many instances the remote cause of 
the disease, and also affords not unfrequently a ready 
outlet for the pus at the most depending part of the ab- 
scess, which is an object of great importance. If the 
fang of the tooth should not extend into the antrum, 
a perforation is to be made cautiously with the stilette 
of a small trochar, or a common pointed probe. If, how- 



ELEMENTS OP SURGERY. 401 

«ver, the teeth be sound, and pus evidently exists in the 
antrum, the third or fourth molar tooth should be remov- 
ed, and an aperture made through its socket into the 
abscess. 

The removal of carious bone should never be attempt- 
ed before it is quite loose ; this process may be very safe- 
ly trusted to the absorbent vessels. 

iiesides inflammation and abscess, the antrum is occa* 
sionally the seat of fungous tumours. These occasion 
an enlargement of the bone, and subsequently an absorp- 
tion of it. The alveolar sockets are protruded down- 
ward, and the teeth pushed out from their sockets. The 
nostril becomes filled up; the excrescence extends in 
every direction; the eye is pushed upward, and in some 
cases the skin ulcerates, and the fungus protrudes 
through it. 

The only remedy is an early extirpation of the tumour, 
by removing a portion of the bone, and dissecting out the 
tumour with a knife and destroying what may remain 
with caustic ; if the disease have made much progress be- 
fore the operation is performed, its efficacy is very doubt- 
ful. In one case I extirpated a very extensive fungous 
tumour, extending almost to the orbitar plate of the upper 
maxillary bone, in a girl, and after a cure was apparent- 
ly nearly effected, the tumour recommenced its growth 
and neither the knife nor caustic had any effect in arrest- 
ing its progress. The disease although not very frequent 
is extremely formidable, and often terminates fatally. 

In the collection of Mr. Heaviside at London, there is 
a skull exhibiting a very extensive bony excrescence from 
the antrum and upper jaw, an engraving of m hich may be 
seen in Mr. Fox's treatise on teeth. The early extir- 
pation of all such tumours is the only remedy in which 
confidence can be placed. 

VOL. T. .^3 



402 ELEMENTS OP SURGERY. 

CHAPTER LXV. 

Diseases of the Tongue. 

The fraenum ImgusB is occasionally too short to allow 
the free motion of the tongue, and it sometimes extends 
to the extremity of the tongue and thus confines it. Chil- 
dren suck with great difficulty in these cases, and it he- 
comes necessary to divide the frsenum. The operation 
is extremely easy, and may be performed either with 
scissors, or, what is better, a sharp pointed bistoury. 
Care should be taken to avoid the ranina artery. 

It is proper to remark that surgeons are often consult- 
ed about children, said to be tongue-tied in whom there 
is- no confinenient of the tongue, a certain difficulty in 
speaking is generally the reason for the supposition ; an 
inspection of the mouth will readily enable the practition- 
er to ascertain whether the tongue is preternaturally con- 
fined or not. 

Ulcers of the tongue arise from various causes and are 
often very difficult of cure. Sometimes a carious tooth 
occasions ulceration of the tongue; this ought certainly 
to be removed or filed smooth. Slits or fissures occasion- 
ally form in the tongue which swells and becomes indu- 
rated in their vicinity. The use of caustic is generally 
proper in these cases. Dr. Physick has employed with 
advantage the actual cautery in a very obstinate case of 
this kind, with a view to change the nature of the sore 
into the state of a burn. 

Cancer occasionally forms on the tongue ; — extirpa- 
tion is the only remedy ; and in performing it, all the dis- 
eased parts should be carefully removed. Mr. Home 
advises in these cases to pass a needle armed with a 



ELEMENTS OF SURGERY. 4^ 

strong double ligature through the middle of the tongue 
beyond the diseased part, and to tie one ligature on each 
side ; in this manner the diseased part being deprived of 
its circulation, will mortify and drop off. The pain is not 
very great, and no danger of hemorrhagy exists. A sa- 
livation in some cases follows, but soon subsides. 

It will be obvious to every one that a little attention 
and dexterity will enable the surgeon to remove such parts 
only as are diseased, leaving the sound parts of the tongue 
uninjured; he should always, however, apply the liga- 
ture in sound parts. If any circumstance should induce 
the surgeon to prefer the knife, he should be careful to 
take up all the bleeding arteries and to have at hand a 
heated iron in case he should be unable to secure them 
with ligatures. I particularly urge this precaution upon 
the young surgeon, because no one unaccustomed to sur- 
gical operations upon the mouth can be aware of the diffi- 
culty of securing a bleeding artery in these parts. 

Ulcers of the tongue are not unfrequently occasioned 
by diseases of the digestive organs — here the remedies 
must be internally administered and different cases call 
for very opposite medicines. In some, alkalies are use- 
ful, in others, acids. Opium has relieved a number of 
these cases. Tartar emetic, in small doses long continued 
has occasionally succeeded. In addition to these reme- 
dies, leeches should be applied in the vicinity of the ulcer, 
and various astringent lotions are to be tried. 

Ulcers from the use of mercury, generally get well 
when the medicine is discontinued. 



4,04) ELEMENTS OF SURGERY. 

CHAPTER LXVI. 

Diseases of the Uvula and Tonsils. 

Inflammation of the throat and fauces produces some- 
times a considerable elongation of the uvula. In gene- 
ral it resumes its usual length after the inflammation 
subsides, but in some cases it is permanently elongat- 
ed, and in these instances should be removed ; — a Ijook 
may be inserted into the uvula to prevent its slipping 
backwards, and then with a pair of scissors a portion of 
it can be easily cut off. There is no danger of hemorr- 
hagy. 

The tonsils in this climate are particularly liable to 
inflammation. In some cases the swelling is very con- 
siderable and breathing and deglutition are greatly imped- 
ed. In these cases, in addition to the remedies em- 
ployed by the physician, scarifications become necessary. 
A sharp scalpel answers the purpose very well. A num- 
ber of small incisions are to be made, and the vessels 
suffered to unload themselves ; the mouth and throat 
should be rinsed with warm water to promote bleeding. 
In case of suppuration the abscess may be opened by a 
common lancet, and great relief will be immediately 
perceived. A particular instrument has been construct- 
ed for the purpose of opening abscesses of the throat, 
called phaiyngotomus, an engraving of which may be seen 
in Brambilla's Instrumentarium. It has no advantage 
over a common lancet or scalpel. 

The tonsils are sometimes enlarged and indurated 
from successive inflammations, and sometimes an en- 
largement occurs without any evident cause. The com- 
plaint is usually, but improperly, denominated schirrhus. 



ELEMENTS OF SURGERY. 405 

It has no disposition to terminate in cancer, but great in- 
convenience is experienced from tlie bulk of the tumour. 
A part or the whole of the tonsil may be removed by 
means of a knife, but in this operation the bleeding is 
sometimes troublesome. Caustic may also be employed, 
but It is the most tedious and painful mode of removing 
the glands. The application of a ligature around its 
base, is I believe the safest and best mode of extirpating 
schirrhus tonsils ; at least I have never seen any incon- 
venience from this method, and I liave seen it very fre- 
quently performed. 

When the base of the tumour is small, a silver wire in a 
double canula, is to be applied round it, in the same man- 
ner as around the root of a polypus ; this wire is to be 
drawn very tight and secured to the shoulders of the in- 
strument. In a great majority of cases this operation is 
very readily performed, and in a few days the turaonr 
drops off. Great care is necessary to make the ligature 
sufficiently tight in order to prevent all circulation in the 
tumour, otherwise a portion of it only will be destroyed, 
the central part remaining after the rest had dropped off. 

When the base of the tumour is large, it is best to cut 
off at least a considerable portion of the gland with a bis- 
toury; the bleeding may in general be restrained by 
washing the mouth with cold water. If the wliole of the 
tonsil be removed with the knife, it is said that a sreat 
discharge of blood takes place. I believe that no dan- 
gerous hemorrhagy would be likely to occur, for if tlie 
bleeding vessels did not speedily contract, it would he 
easy to apply a hot iron and put a check to the discharo-c. 
The great improvements of modern surgery have almost 
entirely banished the actual cautery from practice, but in 
certain hemorrhages from the fauces, it is indispensable. 



4,06 ELEMENTS OF SURGERY. 

CHAPTER LXVII. 

Of Foreign bodies in the (Esophagus. 

Substances occasionally become arrested in the ceso- 
phagus, and by pressing forwards the membranous part 
of the trachea obstruct respiration. I believe with Mr. 
Charles Bell, that the obstruction in these cases is not 
purely of a mechanical nature, but that spasm is excited 
by the irritation produced, and the muscles of the glottis 
diminish very much the aperture through which the air 
passes. 

If the substance be not likely to occasion unpleasant 
consequences in the stomach, it is generally easier to 
push it down than to extract it through the mouth — pins, 
needles, sharp bones, or any pointed substance which 
would probably wound the cesophagus, or any portion of 
the alimentary canal, and also substances which from 
their chemical qualities would be likely to occasion mis- 
chief, as copper coins, &c. should if possible be extracted 
through the mouth. This can only be done when they 
are situated high up near the fauces. If near the sto- 
mach they must be pushed down, and the risk of the con- 
sequences must be incurred. 

To extract substances from the oesophagus the fingei-s 
and forceps are generally the only instruments w hich can 
be employed, and we are very often able to see the fo- 
reign body by pressing down the tongue with a spoon, 
even when the sensations of the patient lead him to 
suppose that it has descended very low; a hook of 
curved wire is also useful in some cases for extracting 
foreign matters, especially when they are of considerable 
size. In two instances I have known the spasm which 



ELEMENTS OF SURGERY. '^J 

had arrested a foreign substance, speedily relaxed by a 
solution of emetic tartar. In each of these cases, a large 
peach stone had slipped into the oesophagus, and the pa- 
tients were of course unable to swallow, and could not 
breathe without great difficulty. They were directed by 
Dr. Physick to hold in their mouths a solution of emetic 
tartar, and attempt to swallow it. Nausea came on, and 
the spasm relaxing, the peach stones were readily dis- 
charged. 

An ingenious mode of extracting small substances, as 
needles, fish-bones, &c. is described by Mr. S. Cooper. 
" The art of employing compressed sponge in the most 
advantageous manner, consists in taking a piece about 
the size of a chesnut, and introducing each end of a strong 
ligature through it. The ends of the ligature are then to 
be passed through a tube, and fastened to that end of the 
instrument which the surgeon holds. The sponge is then 
to be introduced down the cesophagus beyond the foreign 
body, and water is to be injected through the tube, in order 
to moisten the sponge and make it expand. After this the 
ends of the ligature are to be firmly drawn, for the pur- 
pose of pressing the sponge against the extremity of the 
canula to make it expand still more. Then the tube is 
to be withdrawn, together with the sponge, observing to 
twist the instrument to the right and left in this part of the 
operation. 

" When the foreign substance cannot be extracted with 
this instrument a probang may be tried, to the end of 
which a bunch of thread, doubled so as to make an im- 
mense number of nooses, is fastened. Little bodies may 
frequently become entangled, and be extracted in this 
way, when the other one fails.^' 

When the foreign matter cannot be extracted, it be- 
comes necessary to push it forcibly into the stomach, this 
is generally done by means of a probang, a piece of 



408 ELEMENTS OF SURGEKY. 

sponge lied on the end of a whalebone, or large firm 
bougie of waxed linen. In many cases where much in- 
convenience has been anticipated from the nature of the 
foreign substance, it has passed through the alimentary 
canal, without occasioning any great incon\ enience. I 
have known, however, a very extensive fistula in ano, 
produced by a large fragment of bone accidentally swal- 
lowed. 

When the foreign body cannot be either extracted or 
pushed down into the stomach, it sometimes occasions 
very speedy suffocation. Benjamin Bell relates two cases 
of death from this cause, and Desault mentions one in- 
stance in which a woman swallowed a bone with so much 
voracity that it lodged in the middle of the pharynx and 
occasioned suffocation ; she died in three minutes : nu- 
merous accidents of a like nature have happened. 

In other instances the foreign matter remains for many 
years, occasioning no inconvenience. A boy four years 
old, playing with an English farthing, slipped it into the 
CEsophagus and was unable to swallow or eject it. The 
accident happened in Dublin ; Dr. Dease and several 
other surgeons of eminence attempted to extract it, but 
without success ; the immediate symptoms of suffocation 
soon subsided, and the coin, although very inconvenient 
to the patient in his attempts to swallow, remained with- 
out occasioning any very alarming symptoms. He came 
to America, and was attacked in this city with a vomit- 
ing of blood of which he died after a few liours illness, 
at the age of seventeen years. Upon examination after 
death, I found the coin lodged vertically ia the oesopha- 
gus opposite the bifurcation of the trachea, it was so loose 
as easily to move upwards, its motion downwards was 
Biore difficult. The copper was encrusted with a thick 
coat of dark greenish matter, which was detached at one 
part shewing the metallic surface. How it was detained 



ELEMENTS OF SURGERY. 400 

tliiit^en years in this situation I am at a loss to imagine ; 
certainly it would have hcen an easy matter to have 
pushed it into the stomach, and hy no means impractica- 
ble to have withdrawn it through the mouth. 

Sometimes pins and needles are swallowed, they oc- 
casion abscesses by sticking in the cEsophagus, when 
they get into the stomach they are generally evacuated 
with the faeces. In other instances they travel to differ- 
ent parts of the body, and ultimately approach the sur- 
face. A case is related in the Memoirs of the Academy 
of Surgery, in which a needle remained eighteen years 
before it made its appearance externally, during which 
time very little sensation was occasioned by it. 

The operation of cutting into the oesophagus in order 
to extract foreign bodies, I have never known necessary, 
and I believe it ought very seldom to be done. The 
memoirs of the French Academy contaia, however, two 
cases in which it was successfully performed. 

Whenever suffocation is dreaded, and the patient is 
unable to breathe in consequence of a foreign body in 
the oesophagus, it becomes necessary to maintain the 
communication of air to the lungs, by artificial means 
hereafter to be described. By these means we have it 
in our power to prevent suffocation, and thus to afford 
time for the removal of the foreign body. 



VOL. T. 5^ 



<J,£Q ELEMENTS OF SURGERY. 

CHAPTER LXVm. 

Of Strictures of the (Esophagus. 

The oesophagus being a muscular canal is capable of 
contracting at times and of being again dilated. Occa- 
sionally spasm takes place at a particular part of the 
oesophagus and produces a spasmodic stricture, similar to 
the same disease in the urethra. Permanent strictures 
in the oesophagus also occur, producing a narrowness at 
the part, with thickening of its substance, and at 
length if not prevented, an almost total obliteration of 
the canal. The case in this way proves fatal by cutting 
off supplies of food, from the stomach, unless medical aid 
is successful in relieving it. 

The disease can in no manner be better explained, 
than by a history of cases in which it has occurred. Mr. 
Home has published several in his second volume on 
strictures to which the reader is referred. The com- 
plaint generally commences with a difficulty of degluti- 
tion, gradually increasing until fluids only can be swal- 
lowed, and at last every attempt at deglutition becomes 
extremely painful and attended with a sense of suiToca- 
tion, from the substance passing into the glottis. Ema- 
ciation takes place — hunger is extreme, and the patient 
unless relieved, is literally starved to death. I have 
seen one case in which this actually happened — upon 
dissection the oesophagus was found so nearly oblite- 
rated that a probe could not without difficulty be forced 
through the stricture. 

The treatment recommended by Mr. Home is to dilate 
the stricture by introducing bougies of waxed linen, com- 
mencing with such as readily enter it and gradually 



FXEMENTS OF SURGERY. 4H 

enlarging their diameter so as to dilate it. In some 
cases this metliod is ineffectual, and the progress made in 
dilating the passage is too slow. Mr. Home has em- 
ployed the caustic in such instances with advantage, and 
Dr. Andrews of Madeira, has lately published some ca- 
ses in which the same remedy proved successful. The 
lunar caustic is to be preferred. It must be fastened se- 
curely in the extremity of a bougie, of such a size as to 
pass readily down to the stricture ; another bougie of a 
larger diameter is first to be introduced, and when the re- 
sistance of the stricture is felt the patient by shutting his 
mouth makes a mark with his teeth, upon the instrument^ 
by which the precise distance of the stricture is ascertain- 
ed. This bougie being withdrawn, a^mark correspond- 
ing to it, is to be made on the bougie, armed with caustic, 
which is next to be introduced, and suffered to remain half 
a minute in contact with the stricture ; this may be re- 
peated as often as necessary. In passing the bougie, it 
will be an advantage to preserve as accurately as possi- 
ble the curve which the first instrument had assumed, as 
this facilitates greatly the operation of introducing it. 



4;;£«g ELEMENTS OF SURGERY. 

CHAPTER LXIX. 

Of Obstructions in the Glottis and Trachea. 

Whenever respiration becomes interrupted in conse- 
quence of obstruction in the trachea either from disease, 
or from foreign substances accidentally introduced into 
it, it becomes necessary to make an artificial opening into 
this canal, below the obstructed part, in order to preserve 
the fiee communication of air to the lungs. This has 
generally been done by cutting into the trachea, an ope- 
ration which may be performed with great safety and 
without risk of any permanent inconvenience — this truth 
is established, not only by the frequency with which the 
operation has been performed, but also by the facility 
with which even the most extensive wounds of the wind- 
pipe heal up, after unsuccessful attempts to commit sui- 
cide. 

Although the operation of cutting into the trachea may 
become necessary in a variety of instances, yet the ne- 
cessity for performing it has been greatly diminished by 
the introduction of a plan of treatment in which the 
knife is dispensed with : the passage of a flexible tube 
through the glottis into the trachea. 

The causes which may render one of these operations 
necessary are numerous. Inflammatory swellings in the 
vicinity of the glottis, as in the tonsils, sometimes occa- 
sion great difficulty in breathing, and tliough I have 
never known tracheotomy performed in this place in 
consequence of an enlargement of the tonsils, yet it may 
possibly become necessary. — Tumours sometimes form 
in such situations as to impede respiration by pressing 
on the trachea. — Substances lodging in the oesopliagus,. 
by pressing forward the membranous part of the trachea 



ELE>rENTS OF SURGERV. 418 

^nd exciting spasm of the glottis, lessen the size of its 
cavity so as to cut off tlic free access of air to the lungs. 

In some cases the tongue becomes so much swelled 
from the use of mercury as to till up the mouth, and ob- 
struct respiration. In most of the cases which have been 
enumerated, we may frequently avail ourselves of the in- 
troduction of a large elastic catheter into the trachea, and 
thereby avoid the necessity of tracheotomy. 

The introduction of foreign substances into the glottic 
occasions always great uneasiness, violent coughing, and 
much irritation ; hence it would appear from theory, a 
most imprudent act to force an instrument into this pas- 
sage. Experience, however, proves that no danger re- 
sults from it, and many cases have now occurred which 
establish the fact, that an elastic catheter may be left for 
many days in the trachea without exciting any other in- 
convenience than a convulsive cough at its first introduc- 
tion. Even in cases where the irritability of the parts is 
augmented by inflammation, the introduction of a canula 
into the glottis is easily tolerated. The cough is at first 
violent, but it soon subsides and the patient breathes very 
well through the instrument. 

When the tumour exists in the mouth, and the glottis is 
not diseased, the canula may be passed through the nos- 
tril, and readily finds its way into the windpipe. 

In cases where foreign substances exist in the cesopha- 
gus pressing forward the membranous part of the trachea, 
nothing is easier than to pass a catheter into the glottis 
which will prevent the canal from being closed and allow 
the patient to respire freely. In these cases tracheotomy 
has often been performed— a surgeon once performed the 
operation to relieve from suffocation a young man, who 
for fear of being robbed, had swallowed liis money, tied 
in a rag — it stopped in the pharynx, and Would have 
Jcilled him, Jiad not ti-acheotomy been performed— now 



4,i4j elements of surgery. 

in this aud similar cases, the operation recommended by 
Desault would certainly have prevented suffocation and 
afforded time to extract or force through the oesophagus 
into the stomach the substance arrested there. 

The advantages of the plan are very considerable. The 
operation is not difficult ; — there is no danger from bleed- 
ing vessels ; — no wound to heal ; — no risk of a fistulous 
opening ; — consequences which sometimes follow the ope- 
tation of tracheotomy. 

A tube may with great safety be left a considerable 
time in the trachea ; this fact is established by the case of 
a soldier in the hospital at Lyons, who cut his trachea 
through, and wounded the oesophagus. His surgeon 
introduced a large flexible catheter into the trachea, 
another into the oesophagus, by means of one he was 
nourished, and through the other he breathed during the 
cure. Although the operation of opening the trachea 
may sometimes be dispensed with and the introduction of 
a flexible tube substituted, yet this cannot always be done. 
Tracheotomy becomes necessary in certain cases when 
foreign bodies are lodged in the trachea and cannot be 
coughed up. Writers also mention polypi and other ex- 
crescences in the trachea, as causes demanding the ope- 
ration ; these are, however, very rare. 

Foreign substances having entered the glottis sometimes 
get fixed in the ventricles of the larynx, this accident has 
often happened, they produce less disturbance here than 
in the trachea or glottis, sometimes remaining many years 
without occasioning any unpleasant effects : they must of 
necessity be very small. If the foreign body should rest 
in the glottis so as to impede respiration, no time is to be 
lost, an opening must be made below it, and the substance 
pushed up with a probe. 

When any substance falls into the windpipe, it occa- 
sions violent coughing and difficulty of breathing, attend- 



ELEMENTS OF SURGERY. 415 

ed with the usual symptoms of suffocation ; but if the for- 
eign body be not discharged by the efforts of coughing, 
and death be not occasioned by the obstruction to respi- 
ration, then we are to infer that the substance has passed 
through the glottis into the trachea, the irritation in this 
case is greatly diminished and after a short time entirely 
subsides. Heister relates several instances in which 
foreign bodies have passed down to the bifurcation of 
the trachea, and there remained for many years. 

In consequence of the facility with which the mem- 
branous partition between the oesophagus and trachea 
may be pushed forward, so as to diminish the cavity of 
the latter canal, and of the spasmodic action of the mus- 
cle of the glottis excited by any irritation of these parts, 
it is occasionally difficult to ascertain, whether the for- 
eign substance be actually in the oesophagus, or trachea. 
Indeed mistakes have been made, and the trachea has 
been laid open in cases where nothing has been found in 
it, the obstruction having proceeded from pressure in the 
oesophagus. It is of the utmost importance before pro- 
ceeding to such an operation to ascertain precisely whe- 
ther the body be in the oesophagus or not, and this can 
readily be done by passing a probang or catheter down 
the oesophagus, which will remove all doubt. 

When the catheter is to be introduced, it should be 
one of the largest size in use for the urethra. It is to 
be held as a pen, and passed through the mouth, or if 
this be inconvenient from the nature of the disease, 
through the nostril, at the fauces it readily passes either 
into the laryux or pharynx ; at the former it produces. 
First, A cough and tickling pain^ with desire to vomit, 
and a' spasmodic elevation of the larynx. Secondly, The 
flame of a candle placed before the end of it is blown to 
one side. Thirdly, In passing it still further, resistance 
is felt at the bronchia^. In the pharynx and oesophagus 



^^g ELEMENT'S OF SURGERY. 

there is less irritation — no cough — no blast of air — but 
if some fluid is injected through the tube, the doubt 
ceases : if it pass into the larynx, violent coughing is oc- 
casioned, and it returns ; if on the contrary into the oeso- 
phagus, no inconvenience results. 

When any difficulty is found in passing the tube into 
the glottis, a stilctte may he introduced into it properly 
curved ; by this means it acquires sufQcient firmness to 
be passed through the glottis. When introduced it is 
to be secured to the patient^s night cap, and a piece of 
gjiuzc must be fastened over the orifice of the tube in 
order to prevent the dust and floating matter of the air, 
from being drawn into the lungs. The tube is to be 
often removed and cleansed, as the apertures at its extre- 
mity are soon filled with mucus so as to obstruct the free 
passage of air. 

When the operation of bronchotomy becomes neces- 
sary there are two places of performing it, one at tlie 
lower part of the larynx, the other in the trachea. Tra- 
cheotomy consists in making a puncture between the 
rings of the windpipe, or if necessary for the extraction 
of foreign matters it may be divided longitudinally, for 
a considerable length. But of late the French surgeons 
have preferred very much the division of the larynx, and 
they state tlie following advantages which this operation 
possesses. 

In dividing the membrane between the cricoid and thy- 
roid cartilages the skin and a very small portion of cellu- 
lar membrane are the only substances met with. While in 
tracheotomy, the skin, much cellular substance, and gene- 
rally a part of the thyroid gland, are divided. 

There is never any hemorrhage from the puncture 
between the cricoid and thyroid cartilages, whereas the 
other operation is almost always followed by more or 
less hemorrhage, and this is an important circumstance, 



ELEMENTS OF SURGERY. 417 

because it occasions delay, or, by falling into the trachea, 
produces unpleasant eft'ects. Desault relates an instance 
of a child who died from loss of blood before the opera- 
tion could be completed. The larynx is firmly supported, 
and the operation is easily performed ; in the trachea, so 
much motion is allowed that it is often pushed before the 
knife, and in one case the carotid artery was opened owing 
to this circumstance ; laryngotomy is therefore upon the 
whole to be preferred. 



OPERATION. 



The patient is to be seated, and the head inclined some- 
what backwards, a bistoury and a curved canula adapted 
to the larynx are to be provided. The surgeon placed 
before the patient searches for the space between the thy- 
roid and cricoid cartilages, and makes an incision with the 
bistoury an inch long, through the skin and cellular mem- 
brane, from the bottom of the thyroid to the cricoid car- 
tilage — the edges of this wound being separated, the bis- 
toury is to be passed through the membrane of the tra- 
chea, low down, so as to avoid a small artery sometimes 
found on the lower edge of the thyroid cartilage. If this 
be divided however, it is to be taken up immediately. 
The canula is next introduced and secured by tapes, the 
ancles of the wound covered with lint, and the end of the 

canula with gauze. 

When a foreign substance is to be extracted, the aper- 
ture may be enlarged, by means of a pair of forceps and a 
bistoury ; the forceps when introduced into the wound 
maybe opened so as to stretch the trachea and liberate the 
substance, which may then be extracted, or pushed up- 
wards through the glottis. Tlie cricoid cadilage, if ne- 
cessary, may be cut through in this operation, and a con- 
siderable portion of the thyroid may be divided. 

VOL. I. ^^ 



^£^ ELEMENTS OF SURGERY. 

Where the object has been to remove a foreign sub- 
stance, the wound may be immediately closed, and in ge- 
ueral it soon unites, but it is sometimes necessary to leave 
the canula in the wound, and then great attention must 
be paid to frequently cleansing it, because the collection 
of mucus is so great as to impede the passage of air when 
this caution is neglected. 

I have sometimes found it necessary to introduce a ca- 
nula into the trachea, in cases where it has been opened 
by persons attempting to destroy themselves. In these 
cases it is difficult to prevent the collection of blood and 
mucus in the cavity of the canula, and great care is ne- 
cessary to change the tube frequently, in order to remove 
the obstnictions which may be formed within it. 



I'UAJ'H XV. 



Cana/a for L ar vn^alma v 




ELEMENTS OF SURGERY. 4|^ 

CHAPTER LXX. 

^Accidents and Diseases of the iSar. 

iHE MEATUS AUDiTORius EXTERNus is frequently 
plugged up in children with foreign substances, as corn, 
beads, &c., and in adults with hardened wax. In these 
oases a common eyed probe bent so as to form a hook at 
the perforated extremity, is a very convenient instmment 
for extracting them. The wax if necessary may be soft- 
ened by injections of warm water. In general the hear- 
ing is immediately restored when the passage is cleared. 

Insects sometimes crawl into the ear and excite extreme 
pain ; — a little olive oil poured into the external meatus 
kills them very speedily, and they can be readily extract- 
ed. Worms have occasionally been found in this canal, 
their ova having been previously deposited, probably 
during sleep ; an infusion of tobacco in these cases may 
be poured into the meatus ; it does not irritate the parts, 
and is fatal to the insects. 

Abscesses sometimes form in the vicinity of this canal 
and discharge themselves into it — when this is the case, 
the hearing is generally unimpaired. Should the tym- 
panum, however, be aifected, the bones of the ear are 
sometimes discharged through the membrana tympani 
and hearing is greatly injured or entirely destroyed. 
When the symptoms of inflammation exist in this impor- 
tant organ, the usual remedies for it are to be employed, 
with a view to prevent the formation of pus ; — a number 
of leeches behind th« ear, and blisters afterwards are to 
be applied. Mr. Saunders observes that when these 
remedies arc unsuccessful and matter has formed, it is 
generally evacuated, as far as he has observed, between 



^20 ELEMENTS OF SURGEUY. 

the auricle and mastoid process, or into the meatus. If 
it has been evacuated into the meatus, the opening is most 
commonly small, and the spongy granulations, squeezed 
through a small aperture, assume the appearance of a po- 
lypus. Sometimes the small aperture, by which the mat- 
ter is evacuated, is in this manner even closed, and the 
patient suffers the inconvenience of frequent returns of 
pain from the retention of the discharge. When the parts 
have fallen into this state, it will be expedient to hasten 
the cure by making an incision into the sinus, between the 
auricle and mastoid process. 

It occasionally happens that the bone itself dies, in 
consequence of the sinus being neglected, or the original 
extent of the suppuration. The exfoliating parts are the 
meatus externus of the os temporis or the external lami- 
na of the mastoid process. 

When polypi are found in the external meatus they 
are to be removed by the knife or forceps. 

The CAVITY OF THE TYMPANUM is sometimes, as has 
been remarked, the seat of abscess; in these cases the 
membrane is destroyed, and air passes through the ear 
when the patient closes his mouth and blows forcibly ; 
these abscesses are sometimes the result of common in- 
flammation, and sometimes follow small-pox and other 
diseases. The usual remedies for inflammation are the 
only means of preventing suppuration, and where pus 
is evidently formed, notwithstanding their exhibition, 
Mr. Saunders advises a puncture to be made through the 
membrana tympani, in preference to allowing the abscess 
to burst. When the discharge of pus continues a great 
length of time, astringent injections of white vitriol and 
sugar of lead dissolved in water, may be used. Blisters 
and setons applied behind the ear are also advantageous. 

The EUSTACHIAN TUBE is sometimes obstructed and 
occasions a considerable degree of deafness. A severe 



EIXMENTS OF SURCERY. 421 

catarrh frequently produces a temporary deafness of this 
kind. When this tube is obstructed the patient is unable 
to inflate the tympanum as in health ; the sensation at- 
tending this inflation is more easily felt than described : 
to produce it, is only necessary to make a forcible attempt 
at expiration while the nostrils and mouth are closed. Mr. 
Astley Cooper has proposed when permanent obstructions 
exists in the Eustachian tube, to perforate the membrane 
of the tympanum, an operation which has been repeatedly 
performed, and sometimes with success. I liave tried it 
but without any benefit, though I should have no hesita- 
tion in repeating it, because it can do no harm to a deaf 
person and has in many cases proved beneficial — a 
couching needle or sharp pointed probe answers the pur- 
pose very well — when inserted through the membrana 
tympani a sharp pain is felt, but it quickly subsides. The 
instrument sliould not be pushed so far as to wound the 
parts within the membrane. Air in this manner will be 
admitted to the cavity of the tympanum, and if deafness 
should have arisen from a want of it, it will be relieved. 
Mr. Saunders in one case by this operation instantaneous- 
ly relieved a deafness of thirty years standing — he re- 
commends a large aperture to be made, a small one behjg 
apt to close up. 

Diseases of the labyrinth are very generally beyond 
the reach of surgery. In some cases the parts upon dis- 
section evince no morbid alteration, and the want of sen- 
sation has probably been owing to the state of the nerve. 
In other cases the labyrinth is found filled with a cheesy 
concretion, instead of the natural fluid which should be 

found. 

Mr. Saunders considers most of the diseases of the in- 
ternal ear as depending on the nene of hearing, the por- 
tio mollis of the auditory nerve being probably paralytic. 
Various noises are generall^v perceived by patients la- 



,j,Qc^ ELEMENTS OF SURGERY. 

bouring under deafness from the palsy of the nerve, such 
as the murmuring of water, the hissing of a boiling 
kettle, &c. 

The remedies which have oftenest been useful (and 
they have been but very rarely so) are long continued 
purging, low diet, and the use of mercury, witli blisters, 
issues, and setons applied in the vicinity of the ear. 

Mr. Saunders has known a nervous deafness, origi- 
nating from a syphilitic source, to be relieved completely 
by a mercurial course. Deafness, however, is a very rare 
consequence of the venereal disease, unless when it arises 
from ulcers, or scabs, in the external meatus, in which 
case it is temporaiy, and amounts merely to an external 
obstruction readily removable. 



END OF VOL. 1. 



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